Warwickshire Health and Wellbeing Board s Pharmaceutical Needs Assessment

Transcription

1 Warwickshire Health and Wellbeing Board s Pharmaceutical Needs Assessment April

2 Table of Contents Page Executive Summary 3 Introduction 5 Guidance on how to use the Pharmaceutical Needs Assessment 14 Part A: Necessary Services and Current Provision 16 Community Pharmacy 17 Dispensing doctors 28 Dispensing appliance contractors 28 What are pharmaceutical lists 28 Current provision or pharmaceutical services by pharmacy contractors 30 Current provision or pharmaceutical services by dispensing doctors 40 Public and service user views on pharmaceutical services 43 Part B: Local Need - Health Priorities and Targets 47 Demography of Warwickshire 47 Health and wellbeing in Warwickshire 53 Warwickshire Joint Strategic Needs Assessment 59 Part C: Necessary Services: Assessment to Determine Gaps in Provision 78 Public patient assessment of current local access 78 How can community pharmacies improve access to services? 84 Are there local needs that could be met by developing services? 86 Access to pharmaceutical services by locality 98 Recommendations and Conclusions 119 Appendices Appendix 1 - PNA Working Group membership Appendix 2 - PNA Working Group Terms of Reference Appendix 3 - Pharmacy contractor questionnaire Appendix 4 - Dispensing GP questionnaire Appendix 5a - Public & Patient questionnaire Appendix 5b - Public engagement programme report Appendix 5c - Public & Patient questionnaire responses map Appendix 5d - Public & Patient questionnaire profile Appendix 6 - Consultation report Appendix 7a - Seasonal flu vaccination service providers Appendix 7b - Minor Ailment Scheme providers Appendix 7c - Smoking cessation service providers Appendix 7d - Supervised consumption service providers Appendix 7e - Needle exchange service providers Appendix 7f - EHC service providers Appendix 7g - Chlamydia screening and treatment service providers Appendix 8a - Pharmacy contractor opening hours Appendix 8b - Dispensing GP practice hours Appendix 8c - Locality Map Pharmacies in North Warwcikshire Appendix 8d - Locality Map Pharmacies in Nuneaton & Bedworth Appendix 8e - Locality Map Pharmacies in Rugby Appendix 8f - Locality Map Pharmacies in Warwick Appendix 8g - Locality Map Pharmacies in Stratford-upon-Avon Appendix 8h - Map of Dispensing Doctors Appendix 8j - Key to maps of service provision Appendix 9 - Template for assessment of current service provision 2

3 Executive Summary The Pharmaceutical Needs Assessment (PNA) is an assessment of the pharmaceutical services that are currently provided in Warwickshire including dispensing of prescriptions by community pharmacies, dispensing GPs and other providers, as well as other services available from community pharmacies. The PNA aims to ensure that the current NHS pharmaceutical services provided meet the needs of the local population and to guide decisions about commissioning of future services including whether new pharmacies should be allowed to open. A growing and ageing population in Warwickshire puts increasing pressure on health and social care in addition, dementia rates are increasing, 1 in 4 people smoke, 1 in 4 people are obese and around 1 in 3 people live with at least one long term condition. There are 111 community pharmacies in Warwickshire. It is important therefore to ensure that there are an appropriate number of pharmacies in the right places, offering an appropriate range of services. The PNA helps to achieve this. The pharmaceutical services provided in Warwickshire have been evaluated. This is presented in Part A. Key documents such as the Joint Strategic Needs Assessment have been referenced to ensure that any developments of services mirror the priorities in the local Health and Wellbeing (HWB) Strategy. This is presented in Part B. A county wide survey of the views of the public and service users has also been completed. Part C considers Parts A and B together and aims to identify any gaps in service where there is a need to be filled. The draft PNA will be available for consultation from 17 th November 2014 until 15 th January Responses will then be considered before the final version is published. NHS Regulations state that HWBs must produce their first PNA by no later than 1 st April

4 Findings and Conclusions The views and opinions of the public and patients revealed a generally high level of satisfaction. 94% of respondents are very or fairly satisfied with opening hours Over 93% find it easy or fairly easy to access pharmaceutical services Almost half of respondents need to travel less than one mile to reach a pharmacy or dispensing GP and 75% need to travel less than 2 miles. Over 80% of respondents travel for less than 15 minutes to reach a pharmacy. The PNA has concluded that the level of access to, range, level of choice and delivery of pharmaceutical services currently commissioned, generally meets the needs of the population. The service is provided by appropriately located contractors, delivering services over a period of time to allow reasonable access. There are however opportunities for service development. The public health advisory role within the structure of the Healthy Living Pharmacy programme offers further opportunity for community pharmacies to support the HWB. Pharmacies can maximise their contribution to improving healthcare by utilising to the full, the current service profile available under their contract. A number of survey respondents reported difficulties accessing information about pharmaceutical services - where is the nearest pharmacy that is open at a particular time, late at night, at the weekend or on a bank holiday? There is a need for such up to date information to be made easily accessible to the public. The term pharmaceutical services incorporates a range of services that can be commissioned from community pharmacy. The PNA presents an opportunity for local representatives of community pharmacy contractors to engage with service commissioners to further explore how the development of pharmaceutical services can help to deliver the priorities of the HWB in Warwickshire. 4

5 Introduction What is a Pharmaceutical Needs Assessment (PNA)? A PNA presents a comprehensive picture of pharmaceutical service need and provision. It also reviews access, range and adequacy of services and choice of provider for service users. The main aim of the PNA is to establish and review the current NHS pharmaceutical services provided to the local population ensuring that current and future services are of good quality, are easily accessible, meet local health and pharmaceutical needs and provide good use of NHS financial resources. PNAs are used to guide decisions concerning which NHS funded services need to be provided by local community pharmacies and other providers. The PNA is also an essential tool for deciding if new pharmacies are needed when dealing with applications for entry onto the pharmaceutical list. In summary a PNA is an important commissioning tool. PNA History and Legislative background In 2009 responsibility for PNA development rested with Primary Care Trusts (PCTs). All PCTs were required to prepare a PNA, for publication by February The NHS Warwickshire PNA (v 1.0) was published in January The Health and Social Care Act 2012 established HWBs. The Act transferred responsibility to develop and update PNAs from PCTs to HWBs. The NHS (Pharmaceutical Services and Local Pharmaceutical Services) Regulations 2013 (The 2013 Regulations) state that HWBs must produce their first PNA by no later than 1st April Warwickshire HWB has commissioned the services of NHS Arden Commissioning Support (ACS) to help develop the PNA. Responsibility for using PNAs as the basis for determining market entry to a pharmaceutical list, transferred from PCTs to NHS England from 1 April

6 Under the Act, the Department of Health has powers to make Regulations. Regulations 3-9 and Schedule 1 of the NHS (Pharmaceutical Services and Local Pharmaceutical Services) Regulations 2013 set out the legislative basis for developing and updating PNAs and can be found here: What is a Health and Wellbeing Board? Health and Wellbeing Boards (HWBs) became statutory bodies from April 1, Each Local Authority (LA) has a HWB which oversees the new system for local health commissioning. They have a wide remit across the health and care system, providing strategic oversight and bringing together all the local commissioners. HWBs do not commission services; this is undertaken by the LA. The Warwickshire HWB is based at the Shire Hall in Warwick. LAs and Clinical Commissioning Groups (CCGs) have equal and joint responsibility for producing the Joint Strategic Needs Assessment (JSNA), through the HWB. The JSNA and the Joint Health and Wellbeing Strategy (JHWS) informs the preparation of the PNA. What information will this PNA contain? The content of PNAs is set out in Regulation 4 and Schedule 1 to the 2013 Regulations. This outlines the minimum content requirements for PNAs: the pharmaceutical services provided that are necessary to meet needs in the area; the pharmaceutical services that have been identified by the HWB that are needed in the area, and are not provided (gaps in provision); the other services which are provided, which are not needed, but which have secured improvements or better access to pharmaceutical services in the area; the services that the HWB has identified as not being provided, but which would, if they were to be provided, secure improvements or better access to pharmaceutical services in the area; 6

7 other NHS services provided by a local authority, NHS England, a CCG or an NHS Trust, which affect the needs for pharmaceutical services; explanation of how the assessment has been carried out (including how the consultation was carried out); map of providers of pharmaceutical services. Timelines for publication of first and revised assessments The National Health Service (Pharmaceutical Services and Local Pharmaceutical Services) Regulations 2013 came into force on 1 April 2013; HWBs are required to produce their first PNA by 1 April 2015; HWBs will be required to publish a revised assessment within three years of publication of their first assessment; and HWBs will be required to publish a revised assessment as soon as is reasonably practical after identifying significant changes to the availability of pharmaceutical services since the publication of its PNA unless it is satisfied that making a revised assessment would be a disproportionate response to those changes. If it is determined a full revised assessment is disproportionate, then a supplementary statement will be produced. A supplementary statement is essentially a statement of fact and does not change the need. These statements can and should be produced as necessary. Stakeholders involved in the development of the Warwickshire PNA The HWB delegated responsibility for the development of the PNA to a working group and Terms of Reference were established. (Appendix 1 and Appendix 2). Warwickshire County Council (WCC): WCC is run by elected Councillors who are responsible for ensuring that services the Council provides meet the needs of residents and those who work within the county. They set policies and strategies for the Council and monitor the way in which these are implemented. The day-to-day work of the council is carried out by employees working within directorates. Warwickshire County Council's HWB oversees the new system for local health commissioning. It leads on the strategic planning and coordination of NHS, Public Health, Social Care and related Children's Services. 7

8 Arden, Herefordshire and Worcestershire Area Team (AT), NHS England: NHS England is responsible for commissioning services under the national community pharmacy contract, as well as the other primary care contracts for general practices, dentistry and optometry. It is also responsible for some nationally commissioned public health services. NHS England s Area Teams (ATs) are the local arms of the organisation. There are 27 ATs nationally, the local team being Arden (incorporating Coventry & Warwickshire), Herefordshire & Worcestershire Area Team. The aim is to achieve effective commissioning of services to improve outcomes for people in the Arden, Herefordshire and Worcestershire area. This requires close working with a very wide range of other organisations, such as clinical commissioning groups, provider organisations, local authorities, health and wellbeing boards, the NHS Trust Development Authority, Monitor, the Care Quality Commission, Public Health England and Health Education West Midlands. The ATs are responsible not only for determining applications for pharmacy contracts but also commissioning of enhanced services for pharmacy, contract monitoring, pharmacy opening hours and Electronic Prescription Service (EPS) support. Warwickshire Local Pharmaceutical Committee (LPC): This is the local statutory representative (LRC) committee for the 111 community pharmacies in Warwickshire (including 6 internet pharmacies). There are 13 members of the Committee who are elected for a four year term. The Committee works with the NHS England Area Team, CCGs and the Local Authority to develop community pharmacy based services to support the residents of Warwickshire. The LPC also works closely with the other LRCs in Warwickshire and neighbouring LPCs within the same area team of Arden, Herefordshire & Worcestershire. Warwickshire Local Medical Committee (LMC): LMCs are statutory representative bodies of general medical practitioners elected by their peers at intervals of 3 years. The Committee in Warwickshire has developed close links with many of the stakeholders involved in planning and providing health care in the community and 8

9 fulfils an important role linking the views of general practitioners with these health care organisations. Clinical Commissioning Groups (CCGs): Groups of General Practitioners known as NHS Clinical Commissioning Groups (CCGs) have responsibility for planning and commissioning health services (as opposed to public health services). All GP practices within the area of the CCG are members of the CCGs. CCGs may wish to commission services such as minor ailments services, palliative care schemes, MUR+ and other medicines optimisation services from community pharmacies. The CCGs in Warwickshire are: South Warwickshire, Warwickshire North and Coventry & Rugby CCG. NHS South Warwickshire CCG consists of 36 member GP practices, serving a population of approximately 270,000 whilst NHS Warwickshire North CCG comprises 28 practices with approximately 184,000 registered population. NHS Coventry & Rugby CCG has a total registered population of approximately 460,000 patients including 103,000 registered with the 12 member GP practices in Rugby. Local Professional Networks (LPNs): Each AT has three LPNs covering pharmacy, dentistry and optometry. The LPNs are intended to provide clinical input into the operation of the AT and local commissioning decisions. They will also be the focus for NHS England s work on quality improvement for the three local services. The Pharmacy LPN s specific functions include supporting local authorities with the development of the PNA, helping to develop the community pharmacy role in supporting self care, managing long term conditions, promoting medicines optimisation and developing services commissioned locally by local authorities and CCGs, highlighting inappropriate gaps or overlaps. NHS Arden Commissioning Support (ACS): NHS ACS delivers specialist support for healthcare providers and clinical commissioners, providing expertise and innovation to support clinical decision making to improve patient experience and outcomes. NHS ACS works closely with local authorities and other partners to provide integrated commissioning support across health and social care. The 9

10 organisation was created as result of the Health and Social Care Act 2012 and is hosted by NHS England. Methods used for identifying providers of pharmaceutical services Details of providers of pharmaceutical services including community pharmacies, dispensing GPs, Dispensing Appliance Contractors (DACs) and internet pharmacies were preferentially obtained directly from contractors. Where information was not provided by the contractor, this was sourced from NHS England AT. Localities used for considering pharmaceutical services The PNA Working Group determined that previously defined localities (as contained in the Warwickshire PCT PNA 2011) were still relevant and saw no reason why the defined localities should be changed. These localities are used for many of the LA and HWB resources and documents and so uniformity of locality definition would facilitate cross referencing with the PNA. 10

11 Consultation and review As part of the process of developing the PNA, various engagement activities have taken place to ensure valuable input was obtained from key stakeholders. These activities have included: regular working group meetings distribution of contractor questionnaires distribution of public questionnaires focus groups The local authority s duty to involve was first introduced in the Local Government and Public Involvement in Health Act 2007 and was updated and extended in the Local Democracy, Economic Development and Construction Act The 2013 Regulations set out that HWBs must consult the following bodies at least once during the process of developing the PNA: a) any Local Pharmaceutical Committee for its area (including any Local Pharmaceutical Committee for part of its area or for its area and that of all or part of the area of one or more other HWBs); (b) any Local Medical Committee for its area (including any Local Medical Committee for part of its area or for its area and that of all or part of the area of one or more other HWBs); (c) any persons on the pharmaceutical lists and any dispensing doctors list for its area; (d) any LPS chemist in its area with whom the NHSCB has made arrangements for the provision of any local pharmaceutical services; (e) any Local Healthwatch organisation for its area, and any other patient, consumer or community group in its area which in the opinion of HWB has an interest in the provision of pharmaceutical services in its area; and (f) any NHS trust or NHS foundation trust in its area; (g) the NHSCB; and (h) any neighbouring HWB 11

12 Any neighbouring HWBs who are consulted should ensure any LRC in the area which is different from the LRC for the original HWB s area is consulted. There is a minimum period of 60 days for consultation responses and those being consulted can be directed to a website address containing the draft PNA but should, if they request, be sent an electronic or hard copy version. Process for development of the PNA An introductory meeting was arranged between ACS and WCC with representatives from the main stakeholders. The full membership of the PNA working group was agreed (Appendix 1) along with Terms of Reference (Appendix 2) and a timetable was prepared. A joint professional statement was agreed with the aim of promoting the work to contractors highlighting the importance of engaging with the PNA process. This was made available on the LPC, LMC and WCC websites and was distributed via to all contractors. A supplementary statement was prepared to summarise changes to PNA v1 (Jan 2011) The previously determined localities were discussed and confirmed as still relevant by the PNA working group. Contractors were asked to contribute a service profile with their contracted opening times and details of their services and premises. A link to these questionnaires via SurveyMonkey was shared with contractors (Appendix 3 and Appendix 4). These details were then collated and locations of premises mapped. Thirteen community pharmacies failed to return completed questionnaires and so essential data for these pharmacies was sourced from NHS England. Where data has been obtained from a source other than direct from the contractor, this is noted in the relevant section of the PNA. A county wide survey of the views of the public and service users has been completed involving an extensive engagement programme using survey 12

13 questionnaires and focus groups. The central activity involved distributing a link to an online questionnaire throughout July and August, distribution of hard-copy surveys and carrying out focus groups and structured interviews (Appendix 5a, 5b, and 5d). The postcodes of survey responseders were mapped (Appendix 5c). Six separate PNA focus group discussions were completed in August and September Group Demographic Young People Healthwatch 1 to 1 interviews 17yrs and 19 yrs Activitea Older People Action Aged 60+ Chandos Place Luncheon Group Aged many with multiple LTCs Health Watch Volunteers: Adults interested in health matters, inc carers for those with LTCs Grapevine s Speak Up group Adults with Learning Disabilities CCG Patients Conference District Nuneaton and Bedworth Warwick District Warwick District North Warks, Nuneaton & Bedworth, Warwick District North Warks Rugby Key documents such as the Joint Strategic Needs Assessment that examine local health needs have been referenced and have influenced the PNA to ensure that any developments of pharmaceutical services mirror the local Warwickshire Health & Wellbeing Strategy strategy with the aim of improving health and wellbeing and reducing inequalities. The pharmaceutical services delivered by Warwickshire contractors (including community pharmacies and dispensing doctors) have been evaluated. Parts A and B of the PNA summarise the current provision of pharmaceutical services by providers and the local needs and priorities as identified by the HWB. Part C considers Parts A and B together and aims to identify any gaps in service where there is a need to be filled. All information was drawn together and edited to produce the draft PNA document. 13

14 The formal consultation on this document (as defined by regulation) will take place / took place over 60 days from 17th November 2014 until 16th January For more detail see the consultation report (Appendix 6) Guidance on how to use the PNA The PNA has been configured to enable both service providers and commissioners to access relevant information in a format that is structured and user friendly. Executive Summary: This section summarises the key findings and conclusions that have been identified as a result of the assessment and highlights any gaps between health need and current service provision. Introduction: This section details the background and role of the PNA and is designed to inform those involved in local service provision or local service commissioning who are unfamiliar with the concept of a PNA or pharmaceutical service provision. PART A: Necessary Services and Current Provision This section is a summary of current provision (at time of publication) detailing the pharmaceutical services that are provided by community pharmacy and other providers, together with the times and locations where these services are available. It provides details of the full range of services that community pharmacy provides or potentially can provide. Pharmaceutical services in relation to PNAs include: essential services which every community pharmacy providing NHS pharmaceutical services must provide and is set out in their terms of service. advanced services - services community pharmacy contractors and dispensing appliance contractors can provide subject to accreditation as necessary. Locally commissioned services (known as enhanced services) commissioned by NHS England. 14

15 A number of other services are commissioned from community pharmacies in Warwickshire which are not included in any of the categories above. It is not a requirement that details of such services be included in the PNA. However it is the opinion of the Warwickshire PNA Working Group that a comprehensive assessment of pharmaceutical service provision is necessary to support future commissioning decisions. It is important to recognise that only access and provision of the services listed above can be taken into account when making decisions around applications for new pharmacy contracts ( Market Entry ). PART B: Local Need Health Priorities and Targets: This section considers the locally identified health needs as prioritised by the HWB. A number of key documents have been considered and reviewed that examine the health needs of the local population with the aim of improving health and wellbeing and reducing inequalities. It is important to note however that whilst these documents were accurate at the time of publication, more up to date versions might have been published at a later date and will be available on the Warwickshire County Council website: PART C: Necessary Services and Gaps in Provision: Part C explains how a comparison of provision and need was carried out, using sections A and B, to identify potential gaps in services. This will provide a steer for future commissioning and support decisions on applications for new providers of pharmaceutical services. There is also a consideration of future need and demand to cover the following three years after publication equivalent to the lifetime of this PNA. 15

16 PART A Necessary Services and Current Provision Current provision by all pharmaceutical services providers has been reviewed in order to assess the adequacy of provision. This includes providers and premises within Warwickshire and also those that may lie outside in neighbouring HWB areas but which provide the services to the population within Warwickshire. Examples of this type of service provider are community pharmacies, distanceselling pharmacies (those who provide pharmaceutical services but not face to face on the premises), dispensing appliance contractors and dispensing doctors. What are NHS pharmaceutical services? The pharmaceutical services to which a PNA must relate are all the pharmaceutical services that may be provided under arrangements made by the NHS England for: (a) The provision of pharmaceutical services (including directed services) by a person on a pharmaceutical list. (b) The provision of local pharmaceutical services under an LPS scheme. A Local Pharmaceutical Service (LPS) contract allows NHS England to commission community pharmaceutical services tailored to specific local requirements. (c) The dispensing of drugs and appliances by a person on a dispensing doctors list 16

17 Community Pharmacy What is the community pharmacy contract? The NHS Community Pharmacy Contractual Framework (pharmacy contract) consists of three sets of services: Essential services Advanced services Enhanced and locally commissioned services Pharmacy owners (contractors) must provide all Essential services, but they can choose whether or not they wish to provide Advanced and Enhanced services. Essential services 1. Dispensing the safe supply of medicines or appliances. Advice is given to the patient about the medicines being dispensed and how to use them. Records are kept of all medicines dispensed and significant advice is provided to patients. Where appropriate, referrals and interventions are made. 2. Repeat dispensing the management of repeat medication for up to one year, in partnership with the patient and prescriber. The patient will return to the pharmacy for repeat supplies, without first having to visit the GP surgery. Before dispensing each supply the pharmacy will ascertain the patient s need for a repeat supply of a particular medicine. 3. Disposal of unwanted medicines pharmacies accept unwanted medicines from individuals. The medicines are then safely disposed of by a waste contractor. 4. Promotion of Healthy Lifestyles (Public health) - opportunistic one to one advice is given on healthy lifestyle topics, such as stopping smoking, to certain patient groups who present prescriptions for dispensing. Pharmacies will also get involved in six local campaigns a year, organised by NHS England. Campaign examples may include promotion of flu vaccination uptake, healthy living, or stop smoking. 5. Signposting people to other healthcare providers - pharmacists and staff will refer people to other healthcare professionals or care providers when appropriate. The service also includes referral on to other sources of help such as local or national support groups. 17

18 6. Support for self-care the provision of advice and support by pharmacy staff to enable people to derive maximum benefit from caring for themselves or their families. The main focus is on self-limiting illness, but support for people with long-term conditions is also a feature of the service. 7. Clinical governance pharmacies must have a system of clinical governance to support the provision of excellent care: Requirements include: provision of a practice leaflet for the public production, management and use of standard operating procedures patient safety incident reporting to the National Reporting and Learning Service conducting clinical audits and patient satisfaction surveys having complaints and whistle-blowing policies acting upon drug alerts and product recalls to minimise patient harm having cleanliness and infection control measures in place Advanced services 1. Medicines Use Review (MUR) & Prescription Intervention Service The pharmacist conducts a focused review with the patient regarding their knowledge of their medicines and how they use them to increase their understanding. The review attempts to identify and address any problems they may be experiencing. Where necessary, a referral is made to the patient s GP. The MUR can be conducted on a regular basis, e.g. every 12 months, or on an ad hoc basis, when a significant problem with a patient s medication is highlighted during the dispensing process. At least half of the MURs provided each year must be for patients who fall within one of the national target groups: patients with respiratory disease (e.g. asthma and COPD) patients recently discharged from hospital patient taking a high risk medicine (NSAIDs, anticoagulants and diuretics) 18

19 Medicines experts: up to 50 per cent of patients do not take their medicines as intended; community pharmacists and their teams provide individual support to help patients take their medicines in the way intended by the prescriber. Central role in management of long term conditions: pharmacists currently carry out Medicines Use Reviews (MURs) and provide the New Medicine Service (NMS) to patients who have been newly prescribed certain medicines. Improving Health and Patient Care Through Community Pharmacy EVIDENCE RESOURCE PACK NHS England Dec 2013 MURs are conducted in a private consultation area which ensures patient confidentiality. 2. New Medicine Service (NMS) This service is designed to improve patients understanding of a newly prescribed medicine for a long term condition, and help them get the most from their medicines. Research has shown that after 10 days, two thirds of patients prescribed a new medicine reported problems including side effects, difficulties taking the medicine and a need for further information. The NMS has been designed to fill this identified gap in patient need. The pharmacist will provide the patient with information on their new medicine and how to use it when it is first dispensed or up to a week afterwards. The pharmacist and patient will then agree to meet or speak by telephone in around a fortnight so that the patient has met with the pharmacist on two occasions before their review at 4 weeks with their GP. At this second stage of the service the pharmacist will discuss with the patient how they are getting on with their new medicine. Further information and advice on the use of the medicine will be provided and where the patient is experiencing a problem the pharmacist will seek to agree a solution with the patient. A final consultation (typically days after starting the medicine) will be held to discuss the medicine and whether any issues or concerns identified during the 19

20 previous consultation have been resolved. If the patient is having a significant problem with their new medicine the pharmacist may need to refer the patient to their GP. The NMS is conducted in a private consultation area which ensures patient confidentiality. 3. Appliance Use Review Service (AUR) This service is similar to the MUR service, but it aims to help patients better understand and use their prescribed appliances (e.g. stoma appliances) rather than their medicines by: establishing the way the patient uses the appliance and the patient s experience of such use identifying, discussing and assisting in the resolution of poor or ineffective use of the appliance by the patient advising the patient on the safe and appropriate storage of the appliance and proper disposal of the appliances that are used or unwanted The service is conducted in a private consultation area or in the patient s home. 4. Stoma Appliance Customisation Service This service involves the customisation of a quantity of more than one stoma appliance, based on the patient's measurements or a template. The aim of the service is to ensure proper use and comfortable fitting of the stoma appliance and to improve the duration of usage, thereby reducing waste. Enhanced services This group of services is commissioned by the local NHS England Area Team. This is the only set of services (other than Essential and Advanced) that the PNA is required to include and the only additional services that may be taken into account when decisions are made relating to Market Entry applications. 20

21 The following enhanced service(s) are commissioned from community pharmacies in Warwickshire by the NHS England Arden, Herefordshire & Worcestershire Area Team: 1. Seasonal Influenza Vaccination Service Administration of the influenza vaccinations to patients in the identified at risk groups A list of providers can be found in Appendix 7a. 2. Minor Ailments Scheme (Warwickshire North Only) Provision of medicines from an agreed limited list to treat minor ailments, thereby relieving the need for a GP consultation A list of providers can be found in Appendix 7b Locally commissioned services (other than Enhanced services) Pharmaceutical services do not include any services commissioned directly from pharmaceutical contractors by LAs or CCGs. However, a decision was made by the PNA Working Group to include in the PNA all additional services that were provided by local pharmacies to allow presentation of a complete picture of commissioning and to help guide future commissioning decisions. It must be stressed that these services cannot be taken into account when considering applications for entry onto the pharmaceutical list. Such services may be commissioned locally by CCGs and LAs in order to meet the needs of their population. The largest group of locally commissioned services fall under the heading of public health services. The following services are commissioned from community pharmacy by Warwickshire County Council: Smoking Cessation Service - Warwickshire Stop Smoking Service commissions community pharmacies to provide support to smokers. The service includes intensive one-to-one support, monitoring and follow-up of clients after the quit date, submission of monitoring information and supply of Nicotine Replacement Therapy 21

22 (NRT). This service is being developed to include specialist services to pregnant women and also access to varenicline (Champix ) via Patient Group Direction (PGD). A list of providers can be found at Appendix 7c. Supervised consumption this service allows the pharmacist to supervise the consumption of prescribed medicines, ensuring that the dose has been administered and consumed as required by the prescription, to the patient. A list of providers can be found at Appendix 7d. Needle exchange Commissioned community pharmacies provide free access to sterile needles and syringes. A list of providers can be found at Appendix 7e. Community Pharmacy sexual health services in Warwickshire are designed to improve access to key treatments including emergency hormonal contraception ( the morning after pill ) and treatment for chlamydia infection. Providers of sexual health services also encourage clients to access mainstream contraceptive services and provide education on available contraception and the prevalence of sexually transmitted diseases. Supply of emergency hormonal contraception (EHC) - The service allows a client to choose to attend an accredited Warwickshire pharmacy (operating within the parameters of a service level agreement and a current EHC PGD) to obtain EHC. A list of providers can be found at Appendix 7f. Chlamydia screening and treatment -The service offers access to the National Chlamydia Screening Programme by providing local additional outlets where people can access screening and, if deemed appropriate access to treatment of Chlamydia infection. A list of providers can be found at Appendix 7g. 22

23 Healthy Living Pharmacy What is a Healthy Living Pharmacy (HLP)? The Healthy Living Pharmacy concept was developed by the Department of Health with the aim of recognising the significant role community pharmacies could play in helping reduce health inequalities by delivering consistent health and wellbeing services, promoting health and providing proactive health advice and interventions. Before a pharmacy can be considered as an HLP, it must already be meeting all the contractual requirements for Essential and Advanced Services provided within the pharmacy contract. To qualify for HLP status, a pharmacy must also meet a set of agreed criteria: Consistently deliver a broad range of health and wellbeing services to a high quality. Promote healthy living & wellbeing as core activity. Support a team that is proactive in promoting health & wellbeing and the community s health at the centre of what it does. Staff must meet locally agreed training and accreditation requirements to provide customers with health and wellbeing advice. They will signpost patients to community pharmacy and other services where appropriate. Is identifiable to the public and other healthcare professionals HLPs aim to improve the health and wellbeing of the local community and help to reduce health inequalities by delivering, through community pharmacies, a broad range of high quality public health services to meet local health needs. Which services can HLPs provide? The services provided as part of HLP are tailored to meet local health needs and build on the existing core pharmacy services with a series of Enhanced Services at three different levels of engagement: promotion (Level 1), prevention (Level 2) and protection (Level 3); these reflect local health need and increasing capability within the pharmacy to deliver. 23

24 There is increasing recognition that community pharmacy can make a significant contribution to improving the public s health. The Healthy Living Pharmacy (HLP) programme is recognised as a successful model for delivery of public health and prevention in a pharmacy setting and has the benefit of being a standardised approach that supports formal quality assurance and aids systematic roll-out. Community Pharmacy & Public Health NHS, Solutions for Public Health 2013 Services that could be commissioned and delivered by HLPs include, for example: smoking, obesity, alcohol, physical activity, sexual health, men s health. New services could also be developed and commissioned based on local health need; the framework is not restrictive. In Warwickshire, the following services are offered as part of the HLP programme: Stop Smoking Emergency Hormonal Contraception Service (PGD with tailored lifestyle advice) Chlamydia screening and treatment As part of the HLP, Quality Marks are issued to those HLP premises that meet the quality and productivity criteria outlined in their local HLP prospectus. This quality mark then allows members of the public to identify which pharmacies are considered Healthy Living Pharmacies. Directed leadership training is provided by the HLP board for one member of pharmacy staff in each pharmacy (usually the pharmacist). One member of staff is required to complete Making Every Contact Count (MECC) training up to level 2. All other members of staff are required to complete MECC up to level 1. There is also a requirement for one member of staff to attend the health promotion training events jointly organised by LPC and PH and to then cascade relavent information to the wider team. 24

25 These pharmacies are part of the Healthy Living Pharmacy programme in Warwickshire: Primary Care 25 Coton Road Nuneaton CV11 5TW Kasli Pharmacy W M Brown Grendon Pharmacy Bilton Pharmacy Lister Chemist Leyes Lane Pharmacy Wellesbourne Pharmacy Boots Tomkinson Rd, Nuneaton, CV10 8BW Unit 2 Valley Road Galley Common Nuneaton CV10 9NH 150 Boot Hill, Baddesley Ensor, CV9 2EW 37 The Green, Bilton, Rugby, CV22 7LZ Bow Fell Shopping Centre, Brownsover, CV21 1LT 35 Leyes Lane, Kenilworth, CV8 2DE 5 Kineton Road Wellesbourne CV35 9NE 1 Westgate House, Market St, CV34 4DH Can familiar public health interventions be delivered in a pharmacy setting, effectively and cost-effectively? An alcohol awareness month was held in Portsmouth in 2010, using scratch cards. Of the 3,332 people who participated 53% received brief advice on drinking levels, 5% received more in depth guidance and 1% were referred to a specialised service. These results have led to a commissioned service. PSNC 2010 In July 2011, in response to proposals from the Chief Pharmaceutical Officer and professional leaders in public health and pharmacy, Ministers established the Pharmacy and Public Health Forum to bring together pharmacy and public health interest to lead the development of the contribution that pharmacies make to public health. It is chaired by Professor Richard Parish, who was at the time the Chief Executive of the Royal Society for Public Health. One of the initial priorities for the Forum, identified by Ministers, was to evaluate and strengthen the evidence base for community pharmacy s potential contribution to public health. Consolidating and developing the evidence base and research for community pharmacy s contribution to public health: a progress report from the Pharmacy and Public Health Forum 25

26 Is the HLP model transferable to a wide variety of settings and populations? Commissioners need to have confidence in the service models they commission but there has been a recognition (not least from within community pharmacy circles) that despite the extensive range of pilot studies and locally designed and commissioned services that have developed over the past decade or so, formal write up and publishing of such work is lacking so that there is a general lack of a sound evidence base. Supportive anecdotal evidence is often available in abundance, but the value of a sound evidence base is now recognised and work to develop such a foundation is ongoing The Public Health White paper and the 2011/12 NHS Operating Framework recognise the growing evidence to support community pharmacy involvement in public health and the skills and expertise of the pharmacy team and their potential to play an increasing role.. community pharmacies are easily accessible and have the potential to be an integral part in the provision of public health services and the development of the new public health service to improve public health and reduce ill health. Healthy Lives, Healthy People our strategy for public health in England. Department of Health (2010)2011/12 NHS Operating Framework) In summary the community pharmacy setting offers: easy accessibility to a healthcare professional for all long opening hours and convenience a health resource on the high street, in supermarkets, in every shopping centre and local communities anonymity, where appropriate flexible setting within an informal environment local businesses well connected to their local communities pharmacy staff that tend to reflect the social and ethnic backgrounds of the populations they serve that sees the well in addition to the unwell and is therefore ideally placed to play a central role in the prevention of ill health. 26

27 Distance selling (Internet) pharmacies Distance selling pharmacies do not have a local presence in the community as they do not have a community pharmacy premises that service users can readily access. They are internet based and as a result provide a service to users across the country irrespective of the locality in which the pharmacy is based. A distance selling pharmacy must not provide Essential services to a person who is present at the pharmacy. However the pharmacy must be able to provide Essential service safely and effectively without face to face contact with staff on the premises. The pharmacy will receive prescriptions via the post and then after dispensing, will send it via courier or a delivery driver to the patient. The pharmacist can talk to the patient via the telephone. A distance selling pharmacy may provide Advanced and Enhanced services on the premises, as long as any Essential service is not provided to persons present at the premises. Local Pharmaceutical Services (LPS) A Local Pharmaceutical Service (LPS) contract allows NHS England to commission community pharmaceutical services tailored to specific local requirements. NHS England has powers to include in LPS contracts other NHS services or other wider services, such as services relating to the provision of education and training. It provides flexibility to include within a single locally negotiated contract a broader or narrower range of services (including services not traditionally associated with pharmacy) than is possible under national pharmacy arrangements set out in the 2013 Regulations. All LPS contracts must, however, include an element of dispensing medicines. The pharmacies who previously operated under the Essential Small Pharmacies scheme were all transferred to an Essential Small Pharmacy LPS contracts from October Originally due to terminate in 2011, the contracts have been amended to terminate in March

28 Dispensing Doctors A Dispensing Doctor is a General Practioner (GP) who under regulation can dispense medication to patients in their care. Only the provision of those services set out in their pharmaceutical services terms of service (Schedules to the 2013 Regulations) is included within the definition of pharmaceutical services and relates only to the dispensing medicines. Dispensing Appliance Contractors (DACs) DACs supply appliances such as stoma bags and accessories, continence bags and catheters and wound management dressings. They do not dispense medicines. There are no DACs situated in Warwicshire, but people may access those situated elsewhere in the country. What are Pharmaceutical Lists? If a person (a pharmacist, a dispenser of appliances, or dispensing doctor) 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 apply to NHS England to be included on a relevant list by proving they are able to meet a pharmaceutical need as set out in the relevant PNA. There are exceptions to this, such as applications for needs not foreseen in the PNA or to provide pharmaceutical services on a distance-selling (internet or mail order only) basis. 28

29 The following are included in a pharmaceutical list. They are: pharmacy contractors (individuals or companies) dispensing appliance contractors (appliance suppliers are a specific sub-set of NHS pharmaceutical contractors who supply, on prescription, appliances such as stoma and incontinence aids, dressings, bandages etc.). They cannot supply medicines. dispensing doctors, who are medical practitioners authorised to provide drugs and appliances in designated rural areas known as controlled localities. local pharmaceutical services (LPS) contractors who provide a level of pharmaceutical services in some HWB areas. 29

30 Current Provision of Pharmaceutical Services by Pharmacy Contractors A questionnaire was sent out to all pharmacy contractors providing Pharmaceutical Services (Appendix 3). The data collected is presented in Appendix 8a, 8c, 8d, 8e, 8f, 8g, 8j and all analysis is based on the responses received. Access Ensuring that there are a number of pharmacies appropriately positioned throughout the county is just part of the considerations when assessing access. Assessment also needs to take into account a number of other criteria including positioning, hours of service, days of the week when service is provided, range of services available, absence of physical barriers and aids to allow access to those with disabilities. Physical access to community pharmacies in Warwickshire Is free car parking available for people outside the pharmacy? Is disabled parking available outside the pharmacy? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% A number of contractors have made ajustments to their premises to help enable physical access for the disadvantaged. 34 premises have fitted automatic doors 15 have ramps outside to enable wheelchair access 9 pharmacies have installed a disability assist buzzer One pharmacy has installed a lift and another has widened the aisles and lowered the healthcare counter 57% of pharmacies have a hearing loop Is the door to the pharmacy accessible for people using pushchairs, wheelchairs and walking frames? Are there any steps to climb when accessing the pharmacy? Hours of Service (Opening Hours) There is access to a pharmaceutical service from a community pharmacy, somewhere in Warwickshire, from each morning, from Monday to Saturday. All 30

31 pharmacies with the exception of one are open by 09:00 (Mon-Fri). All pharmacies are open until 17:00 most of the working week, and approximately 80% are open until Eight pharmacies are open across the county until or beyond. Some pharmacies close for lunch or have half day closing during the week but there is ample coverage from other contractors in each locality during closure times. Does the pharmacy close for lunch? % Yes 32% No 68% The majority of pharmacy contractors in Warwickshire are open at some time during Saturday, even if hours are reduced compared to weekdays. However demand for dispensing services is much lower on Saturday compared to weekdays, as GP surgeries are usually closed. Access is available in the county until in all localities, with an additional pharmacy open until midnight on Saturday. 20% of contractors provide some cover on Sunday and together they provide a county wide pharmaceutical service between the hours of and midnight. However there are other important factors that need to be taken into account before a determination of access in a localitity can be made. These factors take into account the individual needs within localities, and differences in population, geography and demographics etc. These locality assessments are presented in Part C. Other considerations that influence access Arrangements for provision of pharmaceutical services on Bank Holidays are made by NHS England AT. More than a third of community pharmacies in the county have more than one pharmacist on duty during certain periods. This might be in response to demand during particularly busy periods of dispensing or might be to allow a second pharmacist to concentrate on delivery of additional/enhanced services. Such 31

32 services can be demanding in terms of pharmacist time and often require the pharmacist to be based in the consultation room for one to one meetings with the service user which can interfere with the prescription checking role during busy periods. A number of pharmacies have members of staff who are able to speak languages other than English. Such staff members are often not pharmacists. Pharmacy support staff generally live locally, amongst the community that the pharmacy serves. They are therefore often able to communicate well with the local population with their understanding of language and local culture. What languages are spoken by pharmacy staff in addition to English? No. of pharmacies with staff able to speak this language Punjabi 40 Gujarati 25 Hindi 18 Urdu 15 Spanish 6 French 5 A number of other languages are spoken by some individual pharmacy members of staff. These include: Bengali Portuguese Kurdish Polish Catalan Cantonese Mandarin Russian Polish Slovakian Arabic. German Italian Maharati Swahili Ukranian Welsh Gaelic 32

33 Consultation Areas The vast majority (95%) of community pharmacies have a Consultation Area meeting the requirements in the NHS Pharmaceutical Services (Advanced and Enhanced) Directions 2013 and which is also accessible by wheelchair users. These facilities are almost exclusively closed rooms with a door to help ensure confidentiality and are generally well equipped to enable a range of services to be delivered. Community Pharmacy Consultation Areas (CA) Is the CA a closed room with a door? Is the CA accessible with a wheel chair? Are there hand washing facilities in the CA? Do service users have access to toilet facilities? Does the CA have a computer that is linked to the PMR Does the CA allow access to the internet? 0% 20% 40% 60% 80% 100% 33

34 What is the approximate size of the Consultation Area? Size of Consultation Area m 2 No. of pharmacies Under 5m m 2 36 Over 10m 2 19 Over 60% of consultation areas have hand washing facilities available to pharmacist and service user which is a requirement of some service specifications. Over 40% of pharmacies have toilet facilities available to service users which may be a requirement for some service specifications e.g. certain sexual health services that require the service user to provide a sample of urine. Over 70% of pharmacies have computers in the Consultation Area that are linked to the patient medication record (PMR). This allows details from the record that the pharmacy has built up for the service user, to be accessed and considered alongside information ascertained during a consultation. This would be useful for instance, during a Stop Smoking consultation to view past medication that had been taken to support a quit attempt. It would also be extremely useful during a Medicines Use Review (MUR). Are there any other items of equipment or facilities available in the Consultation Area (CA)? All pharmacy Consultation Rooms in Warwickshire are equipped with chairs and a table and approximately half of the rooms have a range of supplementary equipment such as height charts, weighing scales and BMI/weight charts. A small number of CAs have additional equipment such as blood pressure monitors, glucose testing apparatus, cholesterol testing equipment, a couch, chiropody/podiatry chair. Over 71% of community pharmacies expressed a willingness to undertake consultations with patients at home and there is recognition of the precautions necessary to deliver this service as over 52% of pharmacies have a pharmacist who has been assessed under the Disclosure and Barring Service. 34

35 Community pharmacies are required as part of their contract to take account of the individual needs of their patients, under the Equality Act, and to ensure where necessary that people are assessed and provided with the necessary level of aid and pharmaceutical support so that they can cope with their prescribed medication. Pharmacies in Warwickshire provide a range of services to meet their responsibilities under the Equality Act, including monitored dosage systems (MDS). Many contractors provide services well over and above the contractual requirement which are not remunerated. Some examples include: Over 54% of pharmacies carry out assessments in line with requirements of the Equality Act to determine the level of support that some people will require. 38% of pharmacies provide other aids to help with compliance e.g. Easy to open bottles, MAR charts, large print on labels and Braile on packaging Lower shelf available at the front counter for patients in a wheelchair to sign their prescriptions/repeat slip (750mm from floor level) Variety of different 'pill packs' for patient to choose from. We charge 5 monthly if patient does not qualify under DDA assessment Doset boxes, eye dropper holders, pill cutters and crushers and tube squeezers How many working computers does the pharmacy have for dispensing? No. of pharmacies 1 computer 20 2 computers 43 3 computers computers 12 69% of pharmacies in Warwickshire now have a public facing website 36% of pharmacies in Warwickshire are registered for pre-registration pharmacist training 35

36 All pharmacies have internet access with 59% having full access and 41% with restricted access. Most pharmacies are IT enabled to allow opening and management of ed documents. Most pharmacies have access to the internet from the consultation area. This is useful during an MUR where a person needs to be directed to information that would help them to gain a better understanding of the medicines they are taking or the condition being treated. Access to the internet would also be useful as a sign posting tool to help support people with self-care. Does the pharmacy have the facility to open documents in the following formats? % Microsoft Word 94 Microsoft Excel 93 Microsoft Access 57 PDF 98 Are all computers linked and with access to patient records? 92 When open, does the pharmacy access s on a daily basis? 99 Many pharmacies have more than one computer in the pharmacy with over 70% having a computer in the consultation area that is network linked to allow Patient Medication Record (PMR) access; the computer system used with the pharmacy for electronic records. 99% of pharmacies report that they access s on a daily basis which should allow efficient communication with the network of community pharmacies. 36

37 Does the pharmacy dispense appliances? Yes all types Yes excluding stoma appliances Yes excluding incontinence appliances Yes excluding incontinence and stoma appliances Yes just dressings None 0% 20% 40% 60% 80% 100% Over 80% of pharmacies dispense prescriptions for all appliances with approximately 10% dispensing dressings only. Nine pharmacies are currently accreditred providers of the Healthy Living Pharmacy programme. Of those that do not currently take part, two thirds of contractors state that they intend to apply for accreditation by the time of publication. Range of Services Community pharmacies in Warwickshire provide a range of commissioned services, previously mentioned. Lists of providers can be found at Appendix 7a, 7b, 7c, 7d, 7e, 7f, 7g Nearly all pharmacies in the county provide the New Medicine Service and the MUR service. A smaller proportion of contractors provide the Appliance Use Review 37

38 Service (15%) and the Stoma Appliance Customisation Service (16%) although demand for these two services will be much lower. If your pharmacy provides the MUR service, how many MURs have you completed over the last 12 months? Number of MURs completed in the last 12 months No. of pharmacies Less than NB: Contractors are allowed to conduct a maximum of 400 MURs each year Which Advanced Services does your pharmacy provide? New Medicine Service (NMS) 98% Medicines Use Review Service (MUR) 99% Appliance Use Review Service 15% Stoma Appliance Customisation 16% 0% 20% 40% 60% 80% 100% 38

39 Some pharmacies provide other free or private services to their community. These include: BP measurement Diabetes Screening Cholesterol Measurement Weight Management 0% 20% 40% 60% 80% 100% Does your pharmacy provide a Collection and Delivery Service? Yes Collection of prescriptions from surgeries 100% Collection of prescriptions from surgeries which includes putting in the repeat request slip 95% Delivery of dispensed medicines Free of charge 83% Delivery of dispensed medicines Chargeable 3% Delivery of dispensed medicines Selected patient groups only? 11% 100% of pharmacies collect prescriptions from surgeries and the vast majority of these pharmacies (95%) take an active part in the repeat prescription re-ordering process. 90% of pharmacies deliver prescriptions to people at home free of charge with a small proportion (3%) charging for this service. Some pharmacies provide a delivery service to selected groups of people. Community pharmacy contractors were asked if they wished to make any further comments. Many included a statement expressing that they would be willing to provide all professional services that may be commissioned in the future. 39

40 Current Provision of Pharmaceutical Services by Dispensing Doctors Dispensing doctors are general practitioners (GPs) who provide primary healthcare to over nine million people in the UK s rural areas. Only certain people are eligible to receive dispensing services from a dispensing doctor. Many of these live remotely from a community pharmacy in rural areas and so dispensing doctors are allowed to dispense the medicines they prescribe for them. In Warwickshire, 22 dispensing doctor practices provide pharmaceutical services. A questionnaire was sent out to all dispensing doctor contractors providing Pharmaceutical Services (Appendix 4). The data collected is presented in Appendix 8b, 8h, 8j Which transport facilities are available within 100 metres of the premises? 91% of practices (20) have free on-site parking and 100% (22) have disabled parking. Reflecting the rural nature of the locality, most practices have a bus stop nearby and a third have bicycle racks. All are easily accessible with pushchairs although three have steps at the entrance. All premises comply with the 2010 Equalities Act. 40

41 Does the dispensary have the facility to open documents in the following formats? Responses Microsoft Word Microsoft Excel Microsoft Access PDF 100% 96% 64% 96% Total Respondents: 22 64% of practices (14) have a hearing loop. Most practices are IT enabled to receive, open and work with a documents in a variety of formats and 90% of practices access s on a daily basis. Most practices dispense a full range of appliance items (apart from five who do not dispense stoma or incontinence appliances and so the patient would source these from elsewhere). 68% of practices (15) provide a prescription delivery service to patients homes. Nine dispensing practices provide a delivery service free of charge whilst one provides a service with a charge and five practices provide a service to selected groups only. Does the dispensary provide an MDS service? Yes No Responses 67% 33% Fourteen practices provide an MDS service for which there is no charge. When asked are there any other pharmaceutical services provided by the dispensary that you would like considered in PNA the following comments were added by some contractors: Sheduled Repeat Prescription Service- we automatically get repeats ready so patient doesn't need to remember to order Smoking Cessation Service Travel Clinic Nursing home service 41

42 Emergency Contraception Deliver with no charge currently, to patients that need delivery service Collection service for personal sharps containers Return of sharps boxes blister packs for packs dispensary reviews of medication Dispensing review of the use of medication Drug synchronisation Monitored dose/dossette trays 42

43 Public and Service User views on Pharmaceutical Services A county-wide, public-patient engagement programme was carried out to gain insight from the public, patient and service-user perspective about current pharmaceutical service provision as well as to seek views about potential future services. A number of different engagement methods were used in order to capture the views and feedback from a wide variety of service users. The central activity involved distributing a link to an online questionnaire throughout, distribution of hard-copy surveys and carrying out focus groups and structured interviews. The survey questionnaire was widely distributed as hard copies and via electronic links. Copies were also distributed during group meetings and from community pharmacies and dispensing doctors. Approximately 700 completed forms were received and collated for analysis. Many of the respondents to the PNA survey questionnaire were complimentary about the pharmaceutical service they receive. A representative selection of comments is reproduced below: My pharmacy and others in town always provide sympathetic advice and help on whatever topic I raise. I cannot think of anything further they could do for me. It is a wonderful backup to our national health service and each year they provide me with all sorts of important information. A wonderful and freely available service. Our local pharmacy service is very good. Ours is in the next village, otherwise we would have to go into the city for a supermarket pharmacy. Our pharmacy delivers, which is good for a rural community, especially for the elderly. Our pharmacy is excellent. The staff are first class, knowledgeable and understanding. Other than its location being on a hill and having occasional parking problems, everything about the pharmacy is first rate. The pharmacist is the expert and knows what meds we are on Six separate PNA focus group discussions were also completed. 43

44 PNA Focused Discussion Groups: From the six separate events that were held, some shared themes in the participants responses were highlighted. The majority of participants expressed satisfaction with the pharmaceutical services they accessed, stating respect, and communication and the strong customer service skills as important factors. Even where respondents stated that they were partially dissatisfied, once the relationship with the pharmacy was established, they were often reluctant to change their provider. The Young People Healthwatch Focus Group involved one to one sessions with two female participants aged 17 and 19 years. Interviewee 1 was positive about her pharmacy as it was close by and friendly. She thought that delivering prescriptions is a good service particularly for older people and added that the pharmacist involved in this service went over and beyond making sure he s ordered everything. Interviewee 2 was also positive - The people are friendly, there is usually someone that can assist straight away and they will advise on what's best. Most respondents stated the following reasons for why they access a pharmacy: to obtain medicines dispensed on prescription to obtain over the counter purchases including medicines, vitamins and supplements, other healthcare and cosmetic products to gain advice. PNA Focused Discussion Groups. The six separate events revealed some shared themes in the participants responses: Reasons for choosing a particular pharmacy: Convenience of location. Availability of a home delivery service Prescription collection service linked to GP surgery. How people used their pharmacy: To obtain prescribed medicine To obtain advice - some preferring to access from a pharmacy rather than a GP, because it was more accessible, no waiting, no need for an 44

45 appointment, less time-pressured, whereas others would only seek advice from their GP. Over 70% of survey respondents stated that they take regular prescribed medication. Of these, 63% obtain their medication from the same pharmacy and 17% from a dispensing GP, which indicates a significant level of loyalty by patients. Do you require medicines to be prescribed for you regularly by your doctor? Answer Choices Responses Yes 73% No 27% Almost 65% of survey respondents access a pharmacy or dispensing GP at least once a month (and this increases to almost 80% over three months), with 80% of these people consistently visiting the same contractor. This is a sizable cohort of patients and provides an excellent opportunity to communicate important healthcare messages to the community, directed by the HWB and coordinated with community pharmacy and dispensing GPs. More than once a week Once a week On average, how frequently do you use a pharmacy / doctors dispensary / appliance contractor for any reason? Once a month Once every 3 months Twice a year Never 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 45

46 Where do you usually get your prescriptions dispensed? Usually from the same pharmacy 63% Response From a number of preferred pharmacies 5% From any convenient pharmacy (no preference) 12% From my GP Practice Dispensary 17% From an internet / mail-order pharmacy <1% Other (please state) 2% Nearly 86% of respondents collect their own prescriptions and a further 7% depend on either a friend, relative or neighbour. Just over 6% of people rely on a delivery service. What do you value most about your pharmacy? For housebound people the prompt delivery service is essential Plenty of choice of pharmacies - there s always a chemist open there are many chemists to go to General advice without having to go to GP, Immediate advice without an appointment [the pharmacist] is friendly and approachable and not too time limited (sometimes at GP feel that you are very time limited) Pharmacist is very professional friendly and approachable. They are always willing to listen to me and help advise My medicine use review was really helpful. The medicine for my bladder wasn t working...i was taking it at the wrong time...[the pharmacist]...and since then I ve felt good It s a lovely chemist...perfectly near for people to go to [It s] a personal service, very good Free delivery service excellent 46

47 PART B Local Need - Health Priorities and Targets Demography of Warwickshire Warwickshire lies to the south and east of the West Midlands conurbation, and has established links with Coventry, Birmingham and Solihull in the West Midlands region, but also with the South East. Despite the focus of population within the main towns of the county, a significant part of Warwickshire is rural in nature. Warwickshire lies at the heart of Britain s transport network and several key strategic routes pass through the county. Warwickshire is a two-tier local authority and comprises five district / borough areas: North Warwickshire Borough Nuneaton & Bedworth Borough Rugby Borough Stratford-on-Avon District Warwick District The latest population figures from the 2013 mid-year estimates show that Warwickshire is home to 548,729 people. This is an increase of fewer than 1,000 people from the mid-2012 population estimates that were reported by the Office for National Statistics in last year s Quality of Life report. Warwickshire s population has been growing for the past four decades with continued in-migration from the urban areas of Coventry and Birmingham acting as a key factor behind this trend. However, growth has not been consistent across Warwickshire s five districts. Since 2001, Rugby Borough has seen the largest increase in population across the county, up 14.4% from 2001 to The area with the lowest population change is North Warwickshire Borough, up just 0.3% from The number of births in the county is also continuing to rise. Between 2002 and 2012, there was a 19% increase in annual births in Warwickshire with the biggest rise of 31% in Rugby borough. The age of mothers varies across the county with 47

48 Stratford-on-Avon and Warwick districts having the highest percentage aged over 30, at 62% and 63% respectively. The dependency ratio is now 1.70 people of working age for every dependent in the county (those aged under 16 or over 64). The projection for 2021 is 1.48, a fall that will impact on a number of areas such as the economy, education, health and social care. Alongside this general population growth will be a particularly high rate of increase in those aged 65 and over, a trend reflected across all boroughs and districts. The rate of growth increases with age with the eldest age group, those aged 85 and over, projected to increase by more than 190% between 2010 and A growing and ageing population is likely to result in increasing pressure on health and social care services as more people could suffer from long term physical and mental problems such as heart disease, high blood pressure and dementia. Estimates for Warwickshire suggest that approximately 23% of the total population are children and young people aged 0 to 19 years. This proportion is below the equivalent national and regional figures. The largest demographic issue facing the County is that of a rapidly ageing population. In comparison, the total child/young people population in Warwickshire is projected to increase by a much lower rate. Warwickshire is facing a large scale demographic transition as the population ages at a faster rate than the national average. The projected increases will further challenge the existing levels of provision of health, education and social services at a time when public spending is being reduced. In recent years, migration rather than natural increase (births minus deaths) has been the primary factor behind the increase in Warwickshire s population. Since the opening up of the UK labour market to citizens of new member states of the EU, a significant number of migrant workers have come to live and/or work in the county. 48

49 The National End of Life Care Intelligence Network profiles for the county show that the largest underlying causes of death, for the three years from , are cancers and cardiovascular diseases each of which account for nearly 30% of all deaths across the county. During the same period, 39% of deaths occurred either at home or in care homes whereas 55% were in hospitals. Figures for Excess Winter Mortality (EWM) are available at Local Authority level for 2010/11. When the crude hip fracture rates for Warwickshire are looked at by age groups the differences are striking with those aged 85+ accounting for 47% of all the breakages and those aged 80 and over totalling 68%. The 2011 and 2012 Local Authority Health Profiles both showed that in Rugby Borough, hip fractures in the over 65s were significantly worse than the England average. Warwickshire PNA Localities The PNA Working Group concluded that the same localities should be adopted for the PNA 2015 as were used for the PNA It was agreed that no significant changes had occurred to warrant a change and the adoption of localities that mirror the district/borough boundaries enable reference and access to relevant demographic, prevalence and healthcare data. The localities therefore considered were the five district / borough areas Urban/Rural Split Of which: Population Mid-2012 Urban Total Rural Estimates >10k Rural Town & Rural Village & Fringe Dispersed North Warwickshire 25.9% 74.1% 53.9% 20.2% Nuneaton & Bedworth 100.0% 0.0% 0.0% 0.0% Rugby 75.4% 24.6% 10.4% 14.2% Stratford-on-Avon 22.9% 77.1% 43.3% 33.8% Warwick 89.8% 10.2% 2.8% 7.4% Warwickshire 67.5% 32.5% 18.3% 14.2% Sources: Defra Rural and Urban area classification; Office for National Statistics 2012 mid-year population estimates, ( Crown Copyright 2014 Notes: Area totals are based on mid-2012 small area population estimates. They are the most recent small area population estimates available and all figures are rounded to the nearest

50 North Warks Nuneaton/ Bedworth Rugby Borough Stratford District Warwick District Population (by gender) Male% Female% 49.6% 50.4 % 49.3% 50.8% 50.1% 49.9% 48.8% 51.2 % 50% 50 % Warwickshire County: Total 535,982 Male: 265,492 Female: 270,490 Male: 49.5% Female: 50.5% Population (by age group) Children & Young People (0-15 years): Working Age Population (16-64 years): Retirement Age Population (65+): Children & Young People (0-15 years): % Working Age Population (16-64 years): % Retirement Age Population (65+): % 10,897 39,714 11, % 64.2% 18.2% 23,688 77,581 20, % 63.5 % 17.1% 18,899 58,517 16, % 62.1 % 17.8% 21,186 72,125 25, % 60.6% 21.6% 23,355 92,047 23, % 66.3% 16.8% Warwickshire County Children & Young People (0-15 years): Total 98,025 Retirement Age Population (65+): Total 97,973 Working Age Population (16-64 years): Total 339,984 Children & Young People (0-15 years): 18.3% Working Age Population (16-64 years): 63.4% Retirement Age Population (65+): 18% Population urban/rural Urban Population: Warks Total 367,282 Rural Population: Warks Total 168,700 Urban Population: 68.5% Rural Population: 31.5% 26,154 35, % 57.7% 120,837 1, % 1.1% 69,182 25, % 26.6% 26,670 92, % 77.6% 124,439 14, % 10.3% Health Census Indicators Limiting Long-Term Illness: Warks Total 84,795 Limiting Long-Term Illness: Warks % 16.8% Not in good health: Warks Total 41,117 Not in good health: Warks% 8.1% 11, % 5, % 22, % 11, % 14, % 6, % 17, % 7,844 7% 9, % 9, % 50

51 One quarter (25%) of the population of Warwickshire live in Warwick District with the smallest proportion of the county living in North Warwickshire Borough (11%). However, Nuneaton & Bedworth Borough is the most populated area of the county, with 1,592 persons per square km, compared to just 123 persons per square km in Stratford-on-Avon District. Population and Area Area Population Sq. Miles Sq. Km Hectares Mid-2013 estimates Persons per sq. Km Household estimates (2011) North Warwickshire ,516 62, ,800 Nuneaton & Bedworth , ,003 1,592 52,700 Rugby , , ,900 Stratford-on-Avon , , ,900 Warwick , , ,700 Warwickshire 763 1, , , ,000 Sources: Warwickshire Observatory; Office for National Statistics Mid-2013 Estimates and 2011 Census ( Crown Copyright Figures may not sum due to rounding, population and household estimates are rounded to the nearest 100. In each of the districts and boroughs, except for Warwick District, the 40 to 59 year old age group has the largest population. Warwick District tends to have a slightly younger age profile, with 20 to 39 year olds making up 29% of the population. Focusing on the older age groups, Stratford-on-Avon District has the oldest population profile, with 31.2% aged 60 or over, including 6.6% aged 80 or over. Ethnic Groups The ethnic group breakdown of the Warwickshire population based upon information from the 2011 Census. Warwick District has the highest proportion of people from a black and minority ethnic group (BME), with 17% of the total population of the district belonging to this group. Stratford-on-Avon District has the lowest proportion of the population belonging to the BME group at just 6%. 51

52 2011 Census North Nuneaton Rugby Stratford- Warwick Warwickshire Warwickshire & on-avon Bedworth Total All Groups 62, , , , , ,500 Total White 60, ,300 90, , , ,200 of which: British 59, ,400 84, , , ,600 Irish , ,100 5,200 Gypsy or Irish Traveller Other White 700 2,200 5,200 3,500 5,800 17,400 Total BME (including Irish, Gypsy or Irish 2,500 13,900 15,900 7,700 22,900 62,900 Traveller and Other White) of which: Mixed/multiple ethnic group 500 1,400 2,000 1,300 2,800 7,900 Asian/Asian British 600 7,900 5,200 1,500 9,900 25,100 Black/African/Caribbean/Black British 200 1,000 2, ,000 4,400 Other Ethnic Group ,200 2,300 Numbers may not sum due to rounding errors; all figures are rounded to the nearest 100. Source: Office for National Statistics 2011 Census, ( Crown Copyright 2014 The Office for National Statistics (ONS) publishes long-term sub-national population projections. Across Warwickshire as a whole, the highest rates of projected population growth are in the groups aged 50 years and over. The rate of growth increases with age with the eldest age group, those aged 85 and over, projected to increase by more than 40% between 2012 and

53 Health and Wellbeing in Warwickshire According to the World Health Organisation, health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity (World Health Organisation, 1948). This section aims to provide a summary of key issues that influence health and wellbeing in Warwickshire. Life Expectancy The health of people in Warwickshire is generally better than the England average which is reflected in life expectancy for both men and women being higher than the England average. In Warwickshire for , male life expectancy at birth was 79.8 years, whilst for females it was 83.8 years. This compares with 79.1 for males and 82.9 for females in England & Wales. Male life expectancy at birth varied from 78.2 years in Nuneaton & Bedworth Borough to 81.0 years in Stratford-on-Avon District. Female life expectancy at birth varied from 82.3 years in North Warwickshire Borough to 84.9 years in Stratford-on- Avon District. In the County, male life expectancy at age 65 was 18.9 years, for females it was 21.7 years. This was again slightly higher than that for England & Wales. Male life expectancy at age 65 varied from 17.6 years in Nuneaton & Bedworth Borough to 19.8 years in Stratford-on-Avon District. Meanwhile, female life expectancy at age 65 varied from 20.3 years in Nuneaton & Bedworth Borough to 22.7 years in Warwick District. Of particular concern is that life expectancy is 7.8 years lower for men and 7.4 years lower for women in the most deprived areas of Warwickshire than in the least deprived areas. Interestingly, this difference is most pronounced for males in Nuneaton & Bedworth where there is a difference in life expectancy of 8.2 years between those in the most deprived areas of the Borough compared to the least deprived. Notable differences are also apparent within Warwick District and Rugby Borough. This illustrates the health inequalities which persist both across the County as a whole, and at a more local geographical level. 53

54 North Warwickshire Borough Nuneaton & Bedworth Borough Rugby Borough Stratford-on- Avon District Warwick District Warwickshire England General Health Status Self-reported general health is an important measure of the health of the population. Health perceptions, or perceived health status, are subjective rankings by the affected individual of his or her health status. Some people perceive themselves as healthy despite suffering from one or more chronic diseases, whilst others perceive themselves as ill when no objective evidence of disease can be found. The 2011 Census asked residents to rate their own health on a scale of very good to very bad. In Warwickshire, 82% of residents described their health as good or very good in line with national trends. However, just under 5% or 26,500 Warwickshire residents self-reported that they were in very bad or bad health; equivalent to the total population of Stratford-upon-Avon. The table below shows that there are slightly lower proportions of residents who describe their health as very good in North Warwickshire and Nuneaton and Bedworth. Self-reported health status, by District/Borough 60% 50% Very good health Good health Fair health Bad health Very bad health 40% 30% 20% 10% 0% Source: Office for National Statistics (ONS), 2011 Census: General health, Local Authorities in England A more in depth analysis of this data shows a clear geographic split between the northern areas of the County which generally have higher proportions of their populations experiencing bad or very bad health, and the southern areas which have smaller proportions reporting poor health status. The only anomaly to this pattern is 54

55 in parts of Rugby town, which also exhibit relatively high proportions reporting themselves as having bad or very bad health. Daily activities limited by health and/or disability Residents were also asked to rate the degree to which their daily activities are limited by health and/or disability. At 7.7% of residents, Warwickshire records proportionately slightly fewer people whose activities are limited a lot compared with the national average of 8.5%. In Warwickshire, there are 39,743 residents who say that daily activities are limited a little or a lot due to ill health. This is almost equivalent to the entire working population of North Warwickshire. Nuneaton and Bedworth Borough has the largest number of residents (11,484) experiencing limitations to their daily activities when compared with the other Districts and Boroughs. However, the largest increase between 2001 and 2011 occurred in Rugby Borough (+16%). To further illustrate the variation within the County, Nuneaton and Bedworth Borough records the highest proportion of residents whose activities are limited a lot at 9.5% while Warwick District contains the lowest proportion at 6.4%. Premature Mortality In Warwickshire, there were 4,563 premature deaths (defined as deaths before the age of 75) in the three year period , which equates to approximately 30% of all deaths. The county ranks 39th out of 150 local authorities for overall premature deaths per 100,000 population for (where a ranking of 1 indicates the lowest rate nationally). Compared to the national picture, Warwickshire is doing well on most mortality indicators, other than liver disease where it is ranked 47th. However, the county fares less well compared to similar local authorities such as Cambridgeshire, Oxfordshire and Wiltshire, where it ranks 11th out of 15 for overall premature deaths. The table below shows a more detailed breakdown for how Warwickshire compares on the major causes of premature mortality. 55

56 Premature Mortality - National and Similar Areas Rankings for Warwickshire ( ) National Rank (out of 150) Similar areas ranking (out of 15) Premature Deaths (per 100,000 population) Overall premature deaths 39 th 11 th 315 Cancer 24 th 5 th 131 Heart disease & stroke 35 th 10 th 71 Lung disease 23 rd 8 th 25 Liver disease 47 th 12 th 16 N.B. A ranking of 1 indicates the lowest rate Similar areas include: Dorset, Bromley, Cambridgeshire, Oxfordshire, West Sussex, Wiltshire, Cheshire East, Merton, Gloucestershire, North Yorkshire, Essex, North Somerset, East Riding of Yorkshire, York. Premature Mortality Outcomes: Worst Worse than average Better than average Best Source: Longer Lives, Public Health England The county ranks better than average for premature deaths due to cancer and lung disease, but worse than average for premature mortality linked to heart disease & stroke and liver disease. Living in Warwickshire Survey Lifestyle Factors During September 2013, a large-scale household survey entitled Living in Warwickshire was undertaken across the County in an attempt to gain more robust local intelligence on various lifestyle characteristics of the local population. In terms of self-reported weight status, analysis of the survey results showed that 47% of respondents across Warwickshire felt they were about the correct weight. However, 44% felt they were a little overweight, whilst 6% self-reported that they were very overweight with 3% underweight. One in four respondents consumes the recommended amount of five or more portions of fruit and vegetables per day. 20% eat four portions and 27% eat three portions, indicating that just under three-quarters of respondents consume three or more portions of fruit and vegetables per day. 17% of respondents reported eating 56

57 two portions, whilst 9% said they eat 2 portions. Less than 2% of respondents reported consuming no fruit or vegetables. 12% of survey respondents reported themselves as being current smokers. Of those who were smoking, a third were planning to stop, a fifth were concerned smokers, and 16% were in the process of stopping. However, just under a third stated that they were contented smokers. The highest smoking rates were amongst respondents from North Warwickshire and Nuneaton & Bedworth Boroughs. A higher proportion of females than males reported having never smoked, although males are more likely to be ex-smokers. For ex-smokers, nearly half gave up smoking at the first attempt. However, 29% took three or more times to give up. For current smokers, 87% had previously tried to give up smoking at least once, with 31% having tried on three or more occasions. Outlook The Warwickshire Health and Wellbeing Strategy for is currently being developed. The aim of this strategy is to provide Warwickshire s residents and organisations with a picture of which key particular health and wellbeing issues need to be addressed over the next 5 years and how we will work together to achieve this. The strategy uses intelligence from the Warwickshire Joint Strategic Needs Assessment (JSNA) as a means of identifying the most important health and wellbeing issues amongst the local population. A summary of this document relevant to the PNA will be included following publication, during the period of Consultation. Further Information More detailed information and analysis on the major health and wellbeing issues in Warwickshire is presented in the County s Joint Strategic Needs Assessment (JSNA) which can be accessed via the website: Other epidemiological intelligence, insight and analysis is available via the website: 57

58 Public Health England (PHE) Health Profiles provide a snapshot of the overall health of the local population, and highlight potential problems through comparison with other areas and with the national average. Of the 32 indicators included within the Health Profiles, Warwickshire performs at a significantly worse level than the England average for 3 indicators those being smoking status at time of delivery, breastfeeding initiation and those killed or seriously injured on roads. Key Messages There is one indicator for which performance is significantly worse than the England average cross all five districts and boroughs that being smoking status at time of delivery. Child poverty varies across Warwickshire from 10.1% in Stratford-on-Avon District to 20.1% in Nuneaton & Bedworth Borough. Life expectancy for men varies from 78.2 years in Nuneaton & Bedworth Borough to 81.0 years in Stratford-on-Avon District. Life expectancy for women varies from 82.3 years in North Warwickshire Borough to 84.9 years in Stratford-on-Avon District. In year 6, children classified as obese varies from 13.5% in Warwick District to 20.8% in Nuneaton & Bedworth Borough. The Public Health Outcomes Framework Healthy lives, healthy people: Improving outcomes and supporting transparency sets out a vision for public health, desired outcomes and the indicators that will help us understand how well public health is being improved and protected. Warwickshire is performing either better than or similarly to England for each of the indicators that have been updated since the May update of the PHOF. Data for chlamydia diagnoses (18-24 year olds) shows an improvement locally and is now similar to England instead of significantly worse. The two indicators for flu plus the HIV and TB treatment indicators score as significantly worse than England. 58

59 Warwickshire Joint Strategic Needs Asesment (JSNA) The Local Government and Public Involvement in Health Act (2007) placed a duty on upper tier local authorities and PCTs to undertake a JSNA. The year of 2013/14 was a year of significant change for health and social care: The formal introduction of the Health & Wellbeing Board, the move of Public Health into local authorities, the abolition of the Primary Care Trusts (PCTs) and the formal arrival of the Clinical Commissioning Groups and the introduction of Healthwatch. The JSNA is now produced in partnership across Health and Social Care in Warwickshire, although the strategic direction currently remains with the Director of Public Health and the Strategic Director for People Group. The HWB is statutorily responsible for producing the JSNA and developing a Joint Health and Wellbeing Strategy (JHWS), based on the assessment of need outlined in it. The purpose of the JSNA is to analyse the current and future health and wellbeing needs of the local population to inform the commissioning of health, wellbeing and social care services. The Joint Strategic Needs Assessment for Warwickshire contains a number of key messages. Local needs reflect a changing demography with higher birth rates and a population that is living longer. The need for health and care services continues to grow year on year particularly among older residents. The economic situation continues to impact on the population, especially the most vulnerable in society. Lifestyle choices give cause for concern, particularly with regard to the impact on children and young people. Statements of need must underpin and direct the commissioning plans for Health and Social Care organisations. Breastfeeding Across Warwickshire, breastfeeding rates vary enormously. Key data in the south of the county 75%-80% of women initiate breastfeeding and 50% continue to 59

60 breastfeed at 6-8 weeks. In the north, 59% initiate breastfeeding and 33% continue to breastfeed at 6-8 weeks. In the east, 76% initiate and 43% continue at 6-8 weeks. Whilst the rates in the south reflect the national picture, support has to be directed at the north of the county. Evidence based research suggests that women/mothers want good consistent breastfeeding information and support from health professionals. Good facilities to support mum s to breastfeed within the community and public places are also hugely important. Child poverty Numbers of children living in poverty in Warwickshire are rising. Nuneaton & Bedworth Borough is the area of Warwickshire which has the highest levels of child poverty; some neighbourhoods in this borough have over 50% of children living in poverty. Rural poverty is a significant issue in Warwickshire both in the north and south of the county. Barriers to accessing services are the key issues driving poverty in these rural areas. The global recession has impacted on young people in a number of ways but the levels of unemployment amongst year olds in the West Midlands has increased to the highest levels since records began in In Warwickshire, seven of the ten highest youth unemployment rates are located in Nuneaton & Bedworth Borough. Housing Where people live and their type of accommodation can have a profound effect on their health, wellbeing and quality of life, and ability to be independent. The demand for housing in Warwickshire is predicted to continue to grow. This will need to be delivered in the context of a changed planning system, the adoption of the district/borough Local Core Strategies reflecting Housing Needs Assessments for the future, and historically low levels of housing completions across Warwickshire since Housing affordability is likely to remain an issue in Warwickshire. The ratio of lowest quartile house prices have been consistently over six times lowest quartile earnings since 2003 (currently at 6.8) and is unlikely to reduce significantly in the absence of a housing market crash. This means a person earning a low income would need the equivalent of over six years worth of income to afford just the cheapest housing 60

61 available. Family units Providing services for families will need to change to reflect the shifting make-up of family units and how they choose to live. More older people will live independently at home for longer, people will live with their parents in a family home for longer (in North Warwickshire 38% of year olds currently still live with their parents ), and the proportion of single person households will continue to grow. The way that people relate to and identify with their neighbours, localities, communities and social networks is changing. In the future, it is likely that these will be less obviously defined by spatial boundaries, providing a big challenge for organisations used to delivering or commissioning services based on geographic boundaries. Unemployment Despite a fall in unemployment, two specific issues are causing concern. The first issue is that the number of residents unemployed for more than twelve months has increased. Generally speaking, those who have been out of work for longer periods of time will find it increasingly difficult to get a job, as well as having a negative impact on their health and wellbeing. Despite this worrying finding, long term unemployment in Warwickshire remains below the regional and national average. The second issue relates to youth unemployment. The unemployment rate amongst the age group, although now falling, is more than twice the rate of those aged over 24. Furthermore, one third of 18 to 24 year olds that are claiming Jobseekers Allowance in Warwickshire have being doing so for more than six months. Long term unemployment is a particular concern with this age group, as many young people will be seeking their first job. The longer it takes to make that first step into the workforce, the more difficult it becomes. 61

62 Inequalities An inequalities gap exists particularly in the North of the county being most predominantly associated with the relatively poor health status of residents of Nuneaton & Bedworth. Some of the most important inequalities are: the considerable differences in life expectancy between areas of Nuneaton and Bedworth when compared with areas in Warwick; the large differences in the rate of smoking between communities; the numbers of looked after children in the North when compared with the South; educational attainment and its impact on people s employment and earnings and the quality of housing and community that they live in. These examples demonstrate that inequalities still persist and that the gap in inequalities between the North and the South has continued to increase.. Generally, the Quality of Life Report 2013/14 continues to show that the north of the county fares less well than the other districts and boroughs across a range of indicators, with Nuneaton & Bedworth generally being in a slightly worse position than North Warwickshire. Health inequalities In overall health terms, Warwickshire tends to perform better than the national average, however, estimated life expectancy figures, a commonly used proxy health indicator ranks the county lower when compared to others of similar health and geographical profile to Warwickshire. If current mortality rates prevail, a typical boy born today in the county can expect to live around 79 years, while a girl can expect to live around 82 years, both slightly above the England average. This pattern is also consistent at older ages with male life expectancy at 65 (18.1 years) in Warwickshire slightly above the national average. These overall rates mask the differences between the districts of Warwickshire with most of the inequalities being predominantly associated with the relatively poor health status of residents of Nuneaton & Bedworth. Recent figures across the county 62

63 indicate that male life expectancy in Nuneaton & Bedworth is 2.5 years less than in Stratford-on-Avon, and females in Nuneaton & Bedworth can expect to live 2.1 years less than those in Warwick. Learning disabilities Prevalence rates indicate that there are 9,310 people aged 14 and over in Warwickshire with some form of learning disability. This is projected to increase to 9,570 by 2015, with a reduction in numbers aged but a large increase in those aged 65 and over. Physical disability Using the EA definition, there are estimated to be 85,000 disabled people living in Warwickshire - 19% of the population aged over 16. All Warwickshire s districts and boroughs have lower proportions of their adult populations who are disabled than national and regional averages. In 2011, a total of 1,230 people were registered as blind or severely sight impaired in Warwickshire with 1,486 registered as partially sight impaired. It is estimated that there are currently 8,050 people in Warwickshire aged between 18 and 64 with a serious physical disability. The numbers of children with learning disabilities and complex needs surviving in adulthood are also growing, as are those adults surviving with learning disabilities into old age. In addition, those that do survive into older age can face the loss of their existing support from carers, who are no longer able to look after them. The promotion of healthy lifestyles, the provision of information and guidance, and identifying needs at an earlier stage will be required to improve health and wellbeing and increase the numbers of those physically and mentally disabled people living positive and fulfilling lives. Falls In Warwickshire, admission rates for fractured neck of femur are rising year on year, and although these changes are not statistically significant, there were 551 admissions for fractured neck of femur in 2008/9 compared with 483 in 2005/6. Rates are increasing in North Warwickshire, Nuneaton & Bedworth and 63

64 Stratford-on-Avon, and decreasing in other districts/boroughs. However, Rugby residents have the highest rates. Hip fracture admission rates are the most robust measure we have to use as a proxy indicator for falls, but are not reflective of total fall rates. Immunisation In Warwickshire the main issues are: Maintenance of the 95% coverage target for childhood immunisation programme. Increasing the uptake of the second dose of MMR to meet the 95% target. Increasing the uptake of seasonal flu vaccine to those aged 65 years and over. Increasing the uptake of seasonal flu vaccine to those aged less than 65 years in clinical risk groups. Parents need to understand the benefits of flu immunisation and the risk to the health of their children by refusing immunisation. In 2011/12 there were 91 children aged 6 months to 2 years in clinical risk groups for seasonal flu such as those with heart disease, respiratory disease, liver and kidney disease. Only 17 of these children were vaccinated. Ensuring that health professionals not actively involved in immunisation programmes are aware of how to proactively promote immunisation. Physical activity The Health Impacts of Physical Inactivity (HIPI) tool estimates that only 20% of the Warwickshire population are currently physically active and 18% of total premature deaths could be prevented if 100% of the population were physically active. The Health Impacts of Physical Inactivity (HIPI) tool uses estimates of local levels of physical activity from the Sport England Active People survey to estimate how many cases of certain diseases could be prevented if the population aged were to engage in the recommended amounts of physical activity This is equivalent to 388 avoidable deaths in Warwickshire each year. The tool also details that approximately 3,144 cases of diabetes could also be prevented in the county if 100% of the population were active. 64

65 Carers Data from the 2011 Census shows that 11% of people in Warwickshire provide unpaid care for someone. Generally it is the older age groups who provide the most care; 62% of all unpaid carers are aged over 50. Young carers however should not be overlooked, with 2% less than 15 years old. Across the county the carers that provide the most hours of care per week (over 50 hours) are all in the older age groups, i.e. age 65 and over. Nearly 5,000 individuals fall into this category which raises some concerns about their well-being too. Excess winter deaths The number of excess winter deaths in Warwickshire has risen over recent years. 40% of excess winter mortalities are from cardiovascular disease and around 30% from respiratory disease. The greatest increase in deaths during the winter is seen in older people, particularly those aged over 85 years. In Warwickshire, as across all of Britain, cold spells during a mild winter are generally followed: 2 days later by a rise in heart attacks; 5 days later there is a rise in the number of strokes; 12 days later by a rise in respiratory illness. Crime Levels of crime and disorder are consistently found to be the single most important factor influencing the quality of life for Warwickshire residents. This indicator considers levels of recorded crime, as reported by Warwickshire Police, focusing on volume crimes such as burglary, violence, vehicle crime and criminal damage. Between April 2011 and March 2012, a total of 33,886 crimes were recorded in Warwickshire. This represents an increase of 3% on the previous 12 months (32,827 recorded offences). The increase follows a 3% reduction reported in last year s Quality of Life report, and figures have returned to 2009/10 levels. However, it is important to note that current levels of crime are still low compared to recent years. Deprivation Deprivation is a fundamental driver of need and can highlight inequalities on both a geographic and population group basis. The 2010 Indices of Deprivation showed 65

66 that, in overall terms, Warwickshire is not particularly deprived. However, there is considerable variation across the Districts and Boroughs, and at a more localised level, various distinct pockets of severe deprivation exist within the County. Nuneaton & Bedworth has the highest levels of deprivation in the County. The Borough ranks as the 76 th most deprived Local Authority District (out of the 326 Local Authorities in England). In comparison, Stratford-on-Avon District is the least deprived in Warwickshire with a national rank of 303. There are nine SOAs in Warwickshire ranked within the top 10% most deprived SOAs nationally on the overall Index of Multiple Deprivation These are all located within Nuneaton & Bedworth Borough. This compares with six SOAs in the IMD 2007 and only two in the IMD The Index of Multiple Deprivation (IMD 2010) shows that around half of the areas (Super Output Areas) in the county have shown a relative improvement in national rankings since the last Index in However, all of the top 13 most deprived SOAs from the IMD 2007 have shown considerable deterioration in rankings in the IMD 2010, suggesting that the gap between the most and least deprived areas of the county is widening. Although Warwickshire has low overall levels of child poverty, localised pockets with relatively high levels do exist, particularly in Nuneaton, and to a lesser extent in Rugby and Bedworth. There are also dispersed rural pockets both in the rural south and north. Fuel poverty levels have risen across Warwickshire with the highest pockets of need located in rural areas within Stratford-on-Avon District and North Warwickshire Borough. Rising fuel prices and continued pressures on incomes are seen as the main reasons why levels of fuel poverty have increased. Lifestyle factors A number of lifestyle factors related to residents health and wellbeing continue to persist in Warwickshire. Issues around obesity particularly in children, particularly the large increase between reception and year 6, are likely to result in health problems in later life. There is a need, supported by the Marmot Report, to instil healthy lifestyle choices and behaviour at a young age to reduce risks in later life. 66

67 Obesity Obesity can have a severe impact on people s health, increasing the risk of type 2 diabetes, some cancers, and heart and liver disease. In Warwickshire, one in four adults is estimated to be obese, with a body mass index of more than 30. This equates to approximately 110,000 adults and this figure continues to increase. One in five reception age children in Warwickshire are classed as being overweight and obese, but this increases to almost one in three by the time they have reached Year 6 age. These figures emphasise the importance of encouraging healthy eating and exercise at the start of school life in order to reduce the risk of obesity in later years. There are a number of obesity hotspots in Warwickshire primarily in the urban areas of Warwick, Leamington Spa, Bedworth, Nuneaton and Rugby. For the past two years, the prevalence of obesity in Reception aged children has remained the highest in Nuneaton & Bedworth and North Warwickshire. In contrast, the proportions of obese children in all other areas are statistically significantly lower than the Regional & National figures for both Reception and Year 6 age children. Modelled estimates of obesity levels in adults at a sub-regional level have been produced by the Association of Public Health Observatories (APHO). In Warwickshire, one in four adults is estimated to be obese. However, in statistical terms, Warwickshire s prevalence is not significantly different to that for England. The estimated prevalence of obese adults in North Warwickshire(27%) and Nuneaton & Bedworth (29%) Boroughs are significantly higher than the national average. In contrast, the estimated prevalence rate in Warwick District is significantly lower than the England average at 22%. Young people and substance misuse Fewer young people are using illicit drugs in Warwickshire compared with the national average. Cannabis is the most frequently used substance of those that have tried illegal drugs with 2.8% of young people reported using cannabis in the last four weeks. Efforts to reduce drug misuse therefore, must not be diminished. 67

68 In terms of services, Compass provides high quality support to young people in its care. All service users reduce their alcohol and drug use, with 39% leaving drug free. Furthermore, 99% exit their support in a planned way. However, the number of young people accessing the service has continued to reduce raising concern about the identification and referral of young people with problematic substance misuse. Local research would that there is unmet need for those using substances regularly, but not yet problematically. Young people report that they are well informed about alcohol and illegal drugs. The likelihood of a young person having taken illegal drugs increases with age. In Warwickshire, 99.8% of Year 7 (aged 11 and 12) have never taken illegal drugs. By Year 11 (aged 15 and 16), only 80.2% have never taken illegal drugs with 1.9% reporting that they take illegal drugs most days (a decrease of 3.8% compared with 2011). It should be noted that 2011 survey was not subject to the honesty and accuracy measures applied in the 2012 survey and previous surveys. In the period April 2011 to March 2012, there were 994 recorded Opiate and/or Crack Cocaine Users (OCUs) in effective treatment in Warwickshire and a total of 1,062 adults in effective treatment in the County. The 994 OCUs recorded in the latest period is down 9.9% or 109 clients from the previous year, mirroring the trend seen both regionally and nationally. Alcohol Data on alcohol use by young people in Warwickshire indicates that fewer young people are drinking alcohol, those that do are drinking less frequently, and fewer are attending A&E or being admitted to hospital as a result of alcohol misuse. However, comparisons show that more young people are drinking every week in Warwickshire (11%) compared to the 2011 national average (6%). This is consistent for every age group. Efforts to reduce alcohol misuse therefore, must not be diminished. The annual figure for alcohol hospital admissions for under 18 s (published in September 2012) for Warwickshire is per 100,000. In 2011/12, there were 917 clients in treatment in Warwickshire where alcohol was their primary drug. This is down from 1,131 clients for the equivalent 2010/11 period, a reduction of 17.7%. 68

69 There were 656 new presentations to treatment during the year, which represents 72% of the total treatment population. Rate of Alcohol Admissions per 100,000 Population Nuneaton & Bedworth Rugby Stratford-on-Avon Warwick Year Smoking Smoking remains the primary cause of preventable mortality and premature death with over 900 deaths a year in Warwickshire and an estimated 80,000 in England. It is the single biggest preventable cause of health inequalities and increases the risk of cancer (including lung, oesophagus, bladder, liver, stomach, cervix, myeloid leukaemia, bowel and ovary), heart disease, stroke and chronic respiratory disease. It is estimated that 19.1% (Source: Integrated Household Survey, ONS (experimental statistics), 2011/12 data) of people aged over 18 in Warwickshire are smokers, which equates to nearly 83,000 adults. There is a clear socio-economic gradient in terms of smoking prevalence and it is estimated that 33.9% of the county s adults employed in routine and manual occupations are smokers. Prevalence of smoking in pregnancy is high in Warwickshire, with 23% of women smoking at the time of delivery for Quarter /12. This equates to nearly 1,000 babies a year who are being born to women who still smoked at the time of delivery and is a significantly higher rate than the England proportion of 13% for the same period although due to the data collection limitations, prevalence is believed to be higher and it is suggested that significantly higher numbers of women are likely to be smoking earlier in their pregnancy. 69

70 Tobacco kills more people in England than alcohol, suicide, road accidents, other accidents, diabetes and drug misuse put together and is estimated to reduce life expectancy by 16 years in the most deprived areas. The majority of secondary school pupils do not smoke but the results from the 2012 Annual Pupil survey reveal that 11% have smoked once or twice and a further 7% have smoked a few times. 38% reveal that they usually get their cigarettes from a shop or off-licence and 37% reveal that they usually get them from a friend. Smoking related disease costs NHS Warwickshire an estimated 23 million each year and nationally around 2.7billion. Within Warwickshire smokers generate nearly 50,000 hospital bed days costing in excess of 18 million annually. There are twice as many hospital admissions among smokers as amongst nonsmokers and hospital admissions due to smoking is estimated to cost around 10.4 million per year. Deaths from smoking are thought to cost the Warwickshire economy over 13 million annually in lost productivity whilst smoking related home sick days (estimated at 275,000 per year) are believed to cost employers over 10 million per year. The NHS Warwickshire Stop Smoking Services provides effective treatment for stopping smoking however, in line with the national average, only around 7% of smokers access the service. The challenge is to deliver services that both meet the needs of smokers and encourage greater take up. District/Borough Population % Smoking No. (16+) Prevalence Smokers North Warwickshire 51, % 11,395 Nuneaton and Bedworth 101, % 22,714 Rugby 81, % 15,977 Warwick 114, % 17,686 Stratford 100, % 18,976 WARWICKSHIRE 448, % 86,748 Source: Warwickshire Public Health 70

71 Sexual health The rate of under-18 conceptions in Warwickshire for 2011 was 30.9 per 1,000 females aged 15-17, which equates to 299 conceptions. This represents a reduction of 25% from the 1998 baseline rate and a 10% decline on the number of conceptions in However, whilst the 2011 rate is in line with the national figure, it represents one of the highest figures in comparison to our statistical neighbours (Source: Respect Yourself update number 41; ONS teenage conception release). Teenage conception rates in the north of the county remain relatively high with Nuneaton & Bedworth Borough showing only a 5.2% fall and North Warwickshire Borough experiencing a 2% rise. The Department for Health estimates that there are 434 teenage mothers in Warwickshire, only 291 of which are known to Connexions. Of those 291, 29.9% are in education, employment or training. This falls short of the Teenage Pregnancy Strategy target of 60%. An estimated 63 million a year is spent by the NHS on teenage pregnancies. Teenage pregnancies are falling in Warwickshire as a whole, but not at the same rate across all districts and boroughs. Although there are many examples of good practice throughout the county, there is still plenty to do to ensure the sexual health and wellbeing of the population of Warwickshire improves. Chlamydia is the most widely diagnosed STI in Warwickshire and during 2011 out of 1,165 new chlamydia cases in Warwickshire, 80% were aged between It is recommended that sexually active individuals are screened at least annually or on change of sexual partner. Throughout Warwickshire, the rate of chlamydia has been in decline for both the overall population and the aged population. The aged population are at higher risk of chlamydia due to higher sexual activity in this age group, and in 2011 the rate per 1,000 in this age group was 8.12, compared to 1.33 per 1,000 in the general population. There are inequalities in the rate of chlamydia amongst the districts, with consistently (although declining) highest rates across all age groups within Nuneaton and Bedworth and Rugby. 71

72 Genital warts are the second most prevalent STI in Warwickshire, and years olds are again at increased risk. There is only a small amount of variation in rates throughout the county, and a pattern of slight decline has been seen over the past 3 years. A total of 733 cases were diagnosed in Warwickshire in 2011, a reduction of 7% on the previous year. Genital warts are caused by the human-papiloma virus (HPV) which is very transmissible and for which surveillance is extremely difficult. Although higher in the year age group than the general population, the rates of Gonorrhoea, Herpes and Syphilis remain comparatively small and fairly consistent across the county. For HIV, numbers remain small at around 25 cases in Warwickshire diagnosed each year. There were significantly higher numbers of men diagnosed with the disease than women (64% of the cases in 2009 were male). For both sexes and both years, the year age group represents the highest proportion of all HIV diagnoses (40% of cases). Management of long term conditions An estimated 1 in 3 adults in Warwickshire lives with at least one Long Term Condition (LTC). In Warwickshire, this equates to an estimated 147,000 people. However, more recent research suggests the rate may be as high as 42%. LTCs are increasing, partly as a result of the ageing population and unhealthy lifestyle choices. In 2011, a number of priority public health themes were identified including obesity, alcohol misuse and mental health. We are seeing increases in the prevalence of all three, and the implications go beyond just health services. People with LTCs are 2-3 times more likely to experience mental health issues than those without. The numbers of patients recorded on general practice disease registers, in Warwickshire show that there are potentially large numbers of undiagnosed or unrecorded cases of Long Term Conditions (LTCs), especially for coronary heart disease, hypertension, diabetes, chronic obstructive pulmonary disease, asthma and chronic kidney disease. With a growing and ageing population, Warwickshire is predicted to see a significant increase in numbers of long- term conditions. 72

73 The chronic conditions in the table below account for approximately 21,000 hospital admissions and around 3,000 deaths on average each year: Hypertension is the most common LTC in Warwickshire, in terms of both estimated and actual prevalence. The highest number of hospital admissions and average deaths, per year, are for various types of cancer. Warwickshire Condition Estimated Number & Prevalence (%) GP Practice Disease Registers Hospital Admns Avg. per year Deaths Avg. per year All Long Term Conditions 147,000 (33% of adult popn) 20,000 2,800 CHD 25,400 (5.7%) 17,790 (3.2%) 1, Stroke & TIA 11,100 (2.5%) 9,464 (1.7%) 1, Hypertension 148,000 (33.2%) 80,277 (14.6%) Diabetes 34,800 (7.8%) 23,406 (5.2%) COPD 13,400 (3.0%) 8,106 (1.5%) Asthma 46,000 (37,100 adults & 8,900 children) 34,209 (6.2%) Epilepsy 4,200 3,408 (0.8%) Cancer Hypo- thyroidism 2,500 cases per year (incidence) 3,600 (15 in every 1,000 women, 1 in 1,000 men) 9,379 (1.7%) 15,000 1,400 18,479 (3.4%) 12 5 Renal Disease/CKD 41,900 (9.4%) 21,013 (4.8%) For people aged between 16 and 74 living in Warwickshire, the rate of common mental health conditions is per 1,000 population. Common mental health conditions include depression, generalised anxiety disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), phobias and social anxiety disorder. An estimated 46,000 people aged between 16 and 74 in Warwickshire have a common mental health problem. 73

74 Cancer Cancer is a major cause of ill health and death. It is estimated that more than one in three people will develop cancer at some point in their lifetime, and one in four will die from it. The incidence of cancer generally increases with age. Increases in the number of cases are predicted despite the relatively stable rates in recent years, mainly due to the ageing population. 5% of the NHS budget is spent on cancer care, with some estimates suggesting that the overall cost could increase by more than a third in the next decade. There are many different types of cancer, and many different sites of the body where they can occur. Skin cancers are very common but cancer incidence statistics usually exclude non-melanoma skin cancers, which comprise the majority of these. (There are several reasons for this. One reason is that, because these are often simply excised on an outpatient basis, there may be under-ascertainment of cases. Another reason is that spread beyond the original tumour site is unusual, and they are usually cured by excision). Cancer can occur at any age, but it is predominantly a disease of older adults, with only a very small proportion of cases occurring in children. In is expected that, mainly due to the ageing population, the number of cases of cancer will increase in men of all ages by 70% and in women by 35% in the next two decades. Overall, there are approximately 2,500 cases of cancer diagnosed in Warwickshire each year, and about 1,400 deaths (representing about 27% of all mortalities). Mortality rates from breast, prostate, colorectal and lung cancers are generally similar in Warwickshire to the national rates. However, significant differences from national rates are noted as follows: Warwickshire as a whole has a significantly lower mortality rate from lung cancer in both men and women than the national rates. Stratford-on-Avon and Warwick districts have a significantly lower mortality from lung cancer in both men and women than the national rate. 74

75 Nuneaton & Bedworth has a significantly higher mortality rate from lung cancer in men than nationally Cardiovascular disease (CVD) CVD is the leading cause of death in England and worldwide, accounting for a third of all deaths in England. It is thought that most deaths due to CVD are premature and could be prevented by making a number of lifestyle changes including weight reduction, following dietary and physical activity recommendations, stopping smoking and moderation in alcohol consumption. People at high risk of CVD are prescribed medication such as statins to reduce cholesterol level, aspirin to prevent blood clots and blood pressure medication. Mortality rates in Warwickshire from CVD are significantly lower than the national rate, and have decreased by 54.6% since The absolute gap in CVD mortality, for persons under 75 years, between the most deprived and least deprived local areas has decreased by 24.5% between 2001 and 2009; but the relative gap has increased from 97.7% to 357.7% respectively. The total cost of statin prescribing relative to the local population with CHD is higher compared to the national picture. The prevalence of CVD increases significantly after the age of 40 years. The percentage of the population aged 40 years and over is expected to increase in Warwickshire from 25.5% to 27.9% for males and increase from 27.2% to 28.2% for females by The proportion of the population in Warwickshire which is from black and minority ethnic groups is estimated to be 10.3%. South Asian men are more likely to develop CHD at younger age, and have higher rates of myocardial infarction. Black people have the highest stroke mortality rates. Estimates from the Health Survey for England suggest 18.6% of the population in Warwickshire smoke and 22.4% binge drink. Smoking and alcohol misuse increase risk of CVD. 24.9% of the adult population in Warwickshire are obese, higher than 75

76 the England average (24.2%). Obesity and poor diet (independent of obesity) increase the risk of CVD. Communicable diseases Worldwide, infectious diseases are the largest cause of death. In Warwickshire infectious disease is not the big killer as it is in the developing world but it still has a significant effect on quality of life. The four big communicable disease issues within Warwickshire are: Vaccine preventable diseases Gastrointestinal infections Sexually transmitted infections Other childhood infections Immunisation is the most effective method for preventing infectious disease and maintaining the public health of the population. In NHS Warwickshire the aim is to achieve: 95% or greater uptake for all child health vaccines used within the UK national childhood immunisation programme. 75% or greater uptake for the adult seasonal influenza programme. 100% uptake of Hepatitis B vaccination for at risk babies. Maintenance of targeted BCG programme. Diabetes Diabetes affects approximately 2.8 million people in the UK with an estimated 1 million people undiagnosed. This emerging epidemic disproportionably affects ethnic minorities, the socially deprived and is closely related to obesity. In Warwickshire, 5% of the population have diabetes. Over a quarter of people in Warwickshire are obese, increasing to almost a third in Nuneaton & Bedworth. It is likely that these cases registered with GPs in Warwickshire are just the tip of the iceberg. 76

77 Depression is twice as common in diabetic patients (as with all chronic health conditions) and leads to significant reduction in individual disease control. Dementia In 2012/13 in Warwickshire, there were 3,416 patients on the GP disease register for dementia. However, population prevalence data suggests that only 46% of people in Warwickshire with dementia have been formally diagnosed. This equates to around 3,800 people without a formal diagnosis. In line with a growing and ageing population, numbers of people with dementia are set to increase rapidly in the future. Dementia diagnosis rates in Warwickshire appear to be lowest in North Warwickshire Borough where only 38% of people anticipated to have dementia have received a formal diagnosis. The diagnosis rate is highest in Rugby Borough at 51% but even here nearly half of all people expected to have dementia have not been diagnosed. Timely diagnosis are extremely important for the individual and can help contribute to reduced health and social care costs as the person and their family are more likely to access treatment, support and services that can help support them to stay independent for longer. Between 2012 and 2028 the number of people with dementia is projected to increase by 57% (Figures from Projecting Older People Population Information System (POPPI). Predicted number of people with dementia in Warwickshire 2012 to 2028 (Figures from Projecting Older People Population Information System (POPPI). 77

78 PART C Necessary Services: Assessment to Determine Gaps in Provision Parts A and B of this PNA have summarised local needs as identified by the HWB and the current position in terms of provision of pharmaceutical services by pharmaceutical contractors. Part C aims to identify any significant gaps in service provision that constitute a need to be filled. A locality may have adequate provision of essential services, from an adequate number of providers in appropriate locations to meet the needs of the population, but have a need for more specialist services, such as the management of a long-term condition. Public-patient assessment of current local access to pharmaceutical services The responses from the survey questionnaire and PNA Focus Groups were collated to determine whether any gaps in service or service needs, not currently being met were apparent. However the collation suggests a generally high level of satisfaction in terms of access to services. Almost half of respondents need to travel less than one mile to reach a pharmacy or dispensing GP and this increases to almost 75% of respondents needing to travel less than 2 miles to access a pharmacy/dispensing GP. This further increases to 95% need to travel less than 5 miles. Less than 5% or respondents have to travel more than 5 miles to access the service. 78

79 Less than 1 mile Approximately 1 mile More than 2 miles How far do you have to travel to get to your nearest pharmacy / dispensing GP? More than 5 miles 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Over 80% of respondents need to travel for less than 15 minutes to reach a pharmacy and less than 2% need to complete a journey of over 30 minutes. Under 15 minutes minutes More than 30 minutes How long is your usual journey time to your nearest pharmacy / dispensing GP? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Over a third of respondents travel by foot to access a pharmaceutical service and over half travel by car. This accounts for over 93% of respondents. Less than 3% rely on a bus service. Almost 65% of respondents did not identify a barrier to access to a pharmacy. Of those that did identify a barrier, opening hours was the most common reason highlighted. 79

80 Are there any barriers that prevent you from using a pharmacy? % of responses Lack of confidentiality 9% It is difficult to get to a pharmacy 6% The pharmacy isn t open when I need to access it 24% Long waiting times 13% Other 59% The comment from one respondent highlighted that accessibility for individuals can change according to circumstances: How I access a pharmacy is very different depending on whether I am well enough to be at work and so can pop out at lunch time to get whatever I need, or whether I am ill enough to need to be at home. At work, I walk to one of the ones in Warwick, but if I am ill I want one that is close to where you can park a car, so I don't have far to walk. In an emergency I may need to access one at night or on a Sunday, when I would travel further to whichever one I knew was open. Over 93% find it easy or fairly easy to access pharmaceutical services with around 1% stating that access is very difficult. Although the vast majority stated that there were no problems with access, some respondents added comments. A small minority listed the following: problems with parking not open at weekends distance to travel lunch breaks long waits Easy to access Fairly easy to access A little difficult to access Very difficult to access When in need of a pharmacy, how easy do you find it to access the service? (Consider anything that is relevant to you - distance, waiting times, parking, steps, facilities etc.) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 80

81 PNA Focused Discussion Groups: From the six PNA focused discussions and interviews the shared themes in the participants responses relating to accessibility and barriers were as follows: Home delivery of prescription items was reported as an essential lifeline, especially for those participants with limited ability, or who were housebound. Even with a home delivery service, there were reported occasions where people had to go into pharmacy premises, especially since many participants across the discussion groups had failed to receive part of their prescription they were expecting. In some instances this was reported as an issue. Participants noted easy-to-read information and awareness training relating to people with a learning disability as a key way to make pharmaceutical services accessible to all. Opening Hours for Pharmaceutical Services Hours of service of contractors and times when services are available was highlighted as a problem by some respondents. However analysis of the responses to the questionnaire shows a generally high level of satisfaction with opening hours. Over 94% or respondents state that they are very satisfied or fairly satisfied with opening hours. How satisfied are you with the opening times of community pharmacies, doctors surgery dispensaries or appliance contractors that you use? Responses Very satisfied 55% Fairly satisfied 39% Fairly dissatisfied 4% Not at all satisfied 2% The vast majority of respondents access pharmaceutical services on Monday to Friday between 9am and 6pm with a slightly greater level of access in the morning. Less than 13% access before 9am or after 6pm (Mon to Fri). This will be influenced by the fact that this is when most providers are open for access but it might also indicate that pharmacies are generally open when demand is greatest. About a third 81

82 of those questioned access services on a Saturday and 10% on Sunday with Saturday morning being the most preferred time slot outside of Monday to Friday 9am-6pm. Some respondents of course access services on multiple days/times. When do you generally access pharmaceutical services? Monday to Friday Saturday Sunday Total Respondents Before 9am am - 1pm pm - 6pm After 6pm The relatively high number of people who access services on a Saturday morning, when there is a very low output or prescription forms from prescribers to be dispensed, might indicate that pharmacies are being accessed for other services or over the counter medicines as well as for collection of medicines prescribed earlier in the week. Some respondents added comments about hours of service. A representative selection is included below: A 24 hour service in Rugby would be welcome A local out-of-hours service would be beneficial All loca pharmacies close for lunch (1-2pm) and most on Saturday afternoons Longer opening hours so working population can drop in on way to/from work Make services more available on Sundays Our town previously had a rota so that one pharmacy was always open after usual closing hours. This was very useful for urgent prescriptions and for parents with small children who can often come down with illness quickly. We have sufficient pharmacies in the town to expect them to co-operate and offer the service. We need a 24/7 service in Warwickshire. OOH service will not make a prescription up in the middle of the night. 79% of respondents wait for 10 minutes or less to receive their dispensed medicine. Less than 20% wait for between 11 and 30 minutes. 89% of respondents report that 82

83 they consider waiting times to be reasonable.. At the Coventry and Rugby CCG Patients Conference, male and female adult participants of diverse ethnic-origins, with an interest in health matters expressed confidence in their pharmacists. One participant relayed the experience of having her blood pressure tested at the pharmacy, which led her to go to her GP and identify a serious condition which would otherwise have gone untreated. The participants identified the following barriers or areas of dissatisfaction: Stock:: overpromising under-delivering - do not always have what you need especially smaller chemists Limited availability of drugs due to being attached to GP Out of stocks Opening times: Lunchtime closing, not open on Sunday, Waiting times: Waiting too long for prescription, Queuing due to lack of staff Lack of parking The Grapevine s Speak Up group for adults with learning disabilities were highly satisfied with the local pharmacies they accessed. However they made the point that there needs to be a better understanding of people with learning disabilities. This was further expanded amongst the group as the need for better communication skills generally They also emphasised the need for easy-to-read documents The general conclusion following analysis of responses to the public/patient engagement programme is that service users believe that access to pharmaceutical services currently commissioned in Warwickshire is adequate. 83

84 How can community pharmacies improve access to services? There are a number of areas where community pharmacy can contribute to making improvements in health and wellbeing more accessible in Warwickshire. This can be achieved by: Essential pharmaceutical, including general advice and support relating to medication, delivery of public health messages/campaigns, guidance for selfcare and sign posting Advanced pharmaceutical services such as Medicines Use Reviews and New Medicines Service particularly in the case of long term conditions. Enhanced and additional services currently commissioned such as stop smoking and sexual health services. Commissioning of new services specifically to meet local need. Service specifications are often available following completion of pilot services, or they can be developed locally. The MUR template has been used for a more focused service intervention for a particular condition where the provider is paid an enhanced fee to represent the additional tier of service provided. Services that are currently not remunerated (but where merit and benefit is established) and where availability is unpredictable could be considered for commissioning for specific groups of people. There are significant opportunities for councils to commission PH services from community pharmacies as a key element of their health improvement strategies; based on their joint strategic needs assessments (JSNA) and the priorities agreed in the joint health and wellbeing strategy (JHWS). The PNA, linked to the JSNA, should be the basis on which commissioners and providers build their understanding of the contribution of community pharmacies and support their development as providers of PH services appropriate to local circumstances. Community pharmacy local government s new public health role Local Government Association

85 The role of the community pharmacist has undergone rapid expansion in recent years with a significant emphasis now placed on delivering person-focused services, including promoting healthy lifestyles and modification of health-related behaviours, as well as providing medicine-related services. Additional investment in community pharmacy could be strategically and financially beneficial to local government by improving primary and secondary prevention of disease and access to services. For example, councils are now required to commission NHS Health Checks available for people aged from 40 to 74. Pharmacies, as well as GP practices and other local healthcare and community organisations, are potential bidders for this contract. They will need to show, in competing for contracts, that they can provide good quality, cost effective services. Therefore, in addition to investment by local government, pharmacies commissioned to provide expanded services will need themselves to invest in appropriate staff training (and possibly facilities such as a private consulting room or area) to provide consistent, high quality services. Community pharmacy local government s new public health role Local Government Association 2013 With the evidence now available to support commissioning of specific targeted services from community pharmacy, local leaders of these contractors are encouraged to consider the priorities highlighted within the PNA and offer evidence to commissioners of how local pharmacies can help to address the needs that have been identified. Many critical roles in public health are played by people who will not be employed by Public Health England, but who will be part of a wider professional network. A very wide range of clinicians and other professionals from GPs to dentists, pharmacists to nurses, allied health professionals to environmental health officers have essential roles to play in improving and protecting population health and reducing health inequalities. Healthy Lives, Healthy People: Our strategy for public health in England, DH

86 Are there local needs that could be met by developing pharmaceutical services in Warwickshire? The Health and Wellbeing Board (HWB) is tasked with the improvement of the health and wellbeing of the population it serves. It is required by Government to produce a formal strategy outlining how it will achieve these improvements. The Board is guided by the intelligence and information contained within Warwickshire s Joint Strategic Needs Assessments (JSNAs) which can be found at and the Joint Director of Public Health s Annual Reports which can be found at Warwickshire has a health deficit. It is an affluent county in parts but has only little better than average health outcomes compared to the rest of England. In Warwickshire: 20% of people in Warwickshire smoke 25% of people in Warwickshire are obese 1 in 6 adults suffer from some form of mental illness 1 in 3 adults over the age of 16 live with a long term condition.the evidence supporting the role of community pharmacy is strong for certain specific services such as: stopping smoking, cardiovascular disease prevention, blood pressure management, management of diabetes and possibly asthma and heart failure. Consolidating and developing the evidence base and research for community pharmacy s contribution to public health: Public Health England

87 There is good evidence that Minor Ailments Schemes (MASs) have facilitated the transfer of an appreciable amount of the minor ailment care burden from GPs to community pharmacies but strong evidence for beneficial effect on patient health is lacking. It has been proposed that this model (particularly with the growth of pharmacies now providing services over extended hours) might provide opportunities to reduce pressure on out of hours and A&E services. The literature on the contribution of community pharmacy to public health is growing. A considerable body of evidence exists for the role of community pharmacy in a range of services, not only aimed at improving general health, but also at maintaining the health of those with existing disease. The evidence for positive outcomes is strongest in services including smoking cessation, EHC supply, cardiovascular disease prevention, blood pressure management, diabetes and possibly asthma and heart failure. Although published evidence is currently less strong in other areas such as COPD, infection control, substance abuse, weight management and minor ailments schemes, there are some reports of successes in the community pharmacy provision of these services. However further research is required to justify the role of community pharmacy in these areas. Community Pharmacy & Public Health NHS, Solutions for Public Health 2013 Opportunities identified for community pharmacy in the new Public Health service include NHS Health Checks, tackling drug and alcohol misuse, promoting healthy lifestyles and prevention of long term illness and increasing the uptake of seasonal flu vaccination. Community Pharmacy at the heart of public health PSNC 2012 Obesity: It is estimated that 8% of premature adult deaths could be reduced if the population maintained a healthy weight. The prevalence of obesity in adults has increased sharply in recent years. Modelled estimates of obesity levels in adults at a sub-regional level have been produced by the Association of Public Health Observatories (APHO). In Warwickshire, one in four adults is estimated to be obese. The estimated prevalence of obese adults in North Warwickshire (27%) and Nuneaton & Bedworth (29%) are significantly higher than the national average. In 87

88 contrast, the estimated prevalence rate in Warwick District is significantly lower than the England average at 22%. If..we can help to reduce obesity, lower levels of diabetes and liver disease, among other benefits, would result. Enabling Effective Delivery of Health and Wellbeing - An independent report. Department of Health (2010) Healthy eating: The World Health Organisation (WHO) recommends that people should try to eat at least five portions of fruit and vegetables per day as part of a balanced diet to help them stay healthy. On average iin Warwickshire, approximately three quarters of people fail to meet recommended levels of both fruit and vegetable consumption and physical activity. Nuneaton & Bedworth generally performs less well on measures relating to healthy lifestyles, with higher proportions of people eating fewer portions of fruit and vegetables and do less exercise. Healthy Eating: Community pharmacy based weight management reduction programmes appear to show promise, although more evidence is required. An evaluation by the University of Central Lancashire (Vohra 2010) of the Central Lancashire pharmacy weight management service found an average reduction in BMI after 12 months of 2.4 and an average reduction in blood pressure of 9/6 mmhg. The service was also found to be more cost-effective than prescribing antiobesity drugs over 12 months (a cost of 160 per patient compared to per patient) (PSNC 2010a). NHS Coventry provided an individualised service over 12- months aiming to change patient s behaviour, which achieved significant changes in mean BMI, waist circumference, and blood pressure with 86% of recruits losing weight. Of these 27% lost 5% or more of their body mass. PSNC 2010 Physical exercise: The Department for Health recommends that adults should do 150 minutes of physical activity a week. By meeting these recommended levels the risk of heart disease, stroke and type 2 diabetes is reduced by up to 50%. In Warwickshire just over one in ten reported participating in this level of activity, which was higher than the regional proportion but lower than the national proportion. 88

89 There is some minor variation between the districts with the lowest participation levels being reported in North Warwickshire Borough at 9% and the highest reported in Stratford-on-Avon District with 13%. Stratford-on-Avon District is the only area where participation levels are significantly better than the national average. A quarter of the population achieves the recommended levels of exercise. Again, there is some variation between boroughs and districts with the lowest levels being reported in Nuneaton & Bedworth at 25.3% and highest in Stratford-on-Avon with 29.2%. However, it is notable that even in the district achieving the highest levels of exercise, some 70% of people fail to achieve the recommended levels. Opportunities identified for community pharmacy in the new Public Health service include NHS Health Checks, tackling drug and alcohol misuse, promoting healthy lifestyles and prevention of long term illness and increasing the uptake of seasonal flu vaccination. Community Pharmacy at the heart of public health PSNC 2012 Seasonal influenza: Free NHS flu vaccination by injection is offered every year to protect people most at risk of the flu and its complications. Warwickshire pharmacies have been commissioned to provide NHS flu vaccinations. The Local Authority advocated for pharmacies to be commissioned to provide flu vaccination in 2013/14 based on evidence and evaluation of a local pilot pharmacy scheme. Although a smaller proportion is vaccinated in pharmacies compared to General Practice, it represents a number of people that may not have accessed vaccination otherwise. Reasons for choosing pharmacies included more convenience and being unable to attend their GP, with 488 stating that they had never had a flu vaccination before. Community pharmacies see people in every state of health and are ideally placed to play a central role in the prevention of ill health. Examples of services currently offered that could be developed further include testing, screening and immunisation, as well as signposting potential service users to different council and other public services. Community pharmacy local government s new public health role Local Government Association

90 Sexual health: Warwickshire County Council believes all residents, have the right and opportunity to live a healthy sexual and reproductive life. Efforts to improve sexual health in Warwickshire are aimed at reducing the rates of teenage pregnancy and sexually transmitted infections e.g. Chlamydia, Gonorrhoea, Syphilis and HIV (including the late diagnosis of HIV). The Public Health Annual Report 2014 stated that feedback from service users highlights that it is important that there is easy access in the community to Emergency Hormonal Contraception and Chlamydia screens and that young people receive sex positive advice (which acknowledges natural curiosity and encourages openness) wherever they use sexual health services. Emergency hormonal contraception (EHC) services: There is good evidence that community pharmacy based EHC services provide timely access to treatment and are highly rated by women who use them. The sexual health service in City and Hackney PCT was commissioned through community pharmacy to increase access to EHC, especially to those aged under 26. The service signposts hard to reach groups to mainstream contraceptive services and aims to decrease the incidence of sexually transmitted infections among young women by raising awareness and increasing the use of condoms by young people. Between 2005 and 2008 the number of EHC consultations increased by 100% and the number of consultations for under 18 s increased by 200% PSNC 2010 Tobacco control and smoking cessation: Public Health Warwickshire aims to reduce the harm caused by tobacco consumption in the county working in partnership with key strategic groups and organisations across Warwickshire. Over half of the health inequalities between the north and the south of Warwickshire result from differential smoking behaviours. One in two life-long smokers will die from their addiction. At least 20% of our children live in a house where people smoke. Children of smokers are almost twice as likely to be admitted to hospital with breathing difficulties as those that live in a smoke free home. Community attitudes to smoking are probably the most powerful factor in shaping smokers preparedness to quit or continue with their addiction. Stopping smoking even in later life can make big differences to people s health and to how long they live. Quitting on retirement will 90

91 increase life expectancy by an average of three years. Stop smoking services: All the reviews indicate that community pharmacy based stop smoking services provided by trained pharmacy staff are effective and cost effective in helping smokers quit smoking. The the smoking quit rate for the Sheffield Stop Smoking Service was 55% for community pharmacies (CPs) compared to 42% for GPs. The national average is around 49%. In Hereford between 2004 and 2010, the average quit rate was 48% for CPs (n=2950) compared to 43% for GPs (N=4174). For NHS North Yorkshire, the average quit rate for clients who had set a quit date in was 48% (n=721) for CPs compared to 46% for GP surgeries Quit rates in Healthy Living Pharmacies (HLPs) in Portsmouth were compared between two periods; before initiative and 5 months into initiative, to investigate the impact of HLPs on outcomes. There was a 140% increase in successful quits during the HLP initiative (139 vs.333 quits ). It is estimated that someone walking into an HLP pharmacy would be twice as likely to set a successful quit date and achieve a four week non- smoking status. At 12-week follow-up, 58% of patients through HLPs were still not smoking compared to 42% through non-hlps. Consolidating and developing the evidence base and research for community pharmacy s contribution to public health: Pharmacy and Public Health Forum Community pharmacies serve local communities and have the potential to reach large numbers of people who use tobacco. They are able to meet the needs of minority ethnic and disadvantaged groups and those who may have difficulty accessing other community services. The use of nicotine replacement therapy (NRT) and stop smoking techniques are well known, with many patients visiting their pharmacy to commence such treatment. Community pharmacy is now an established and trusted provider of stop smoking services, and an integrated partner of the NHS Stop Smoking services in many areas. Enabling Effective Delivery of Health and Wellbeing -An independent report. Department of Health (2010) 91

92 Alcohol and drug misuse: Public Health Warwickshire aims to reduce the harm caused by drug and alcohol consumption in the county working in partnership with key strategic groups and organisations across Warwickshire. Long term conditions: Around 1 in 3 people live with at least one long term condition in Warwickshire an estimated 147,000 people aged 16 or over. With a growing and ageing population, Warwickshire is predicted to see a significant increase in numbers of long-term conditions. The DPH 2019/10 Annual Report showed almost an estimated 90% increase in 20 years in older people with dementia. In addition, conditions such as diabetes and depression will see more than a 50% increase. 20% of people with high blood pressure do not achieve the recommended level of control. 11% of people with diabetes have dangerously poor levels of blood sugar control. 10% of people with heart failure are not taking the recommended treatment. Hypertension is the most common long-term condition in Warwickshire, in terms of both estimated and actual prevalence. Chronic disease management and prevention: There is good quality evidence to support community pharmacy input into chronic disease management e.g. improvements in lipid levels that were sustained for at least one year in both primary and secondary prevention of coronary heart disease and the management of diabetes notably screening, improved adherence with medicines and reduced blood glucose levels or HbA1c. Consolidating and developing the evidence base and research for community pharmacy s contribution to public health: Public Health England 2014 Making Every Contact Count (MECC) is about encouraging and helping people to make healthier choices to achieve positive long-term behaviour change. MECC is a programme where frontline staff who have on going contact with the public are trained to have a healthy lifestyle chat, if appropriate, and where appropriate encourage and empower, the public to adopt healthier lifestyle behaviours such as stopping smoking, eating healthily or being physically active. The model is very 92

93 suited to the community pharmacy environment e.g. raising the issue of smoking if someone has a bad cough and sign posting to stop smoking services. With more than 50% of premature deaths in western countries being attributable to lifestyle choices, the MECC philosophy can make the most of opportunities to offer advice to individuals on lifestyle matters where appropriate. The evidence of the ban on smoking in workplaces and enclosed public places demonstrates how individual changes in healthy lifestyles can be supported by collective action. We are committed to the Department of Health s policy of Making Every Contact Count using brief interventions of advice and encouragement to change behavior. Chair of the Warwickshire HWB A number of respondents to the public/patient engagement programme made suggestions for how the pharmaceutical services portfolio could be extended and developed. Cholesterol testing - a routine test once per year would be helpful and reassuring. Give pharmacies access to my GP record after asking me If the pharmacy could check my blood pressure when I need to have it done for a review I would nt need to go to the GP to have this done. A phlebotomy service from more chemists Pharmacies should be used for public health initiatives such as health checks More obesity and type 2 diabetes testing and advice are needed Weight management and healthy lifestyle Drop in advice with a private room Consulting doctors or nurses could be available there, especially for those on repeat prescriptions Medicines advice to care homes Prescription intervention service to promote cost effective prescribing Direct referral to GP Ensure dispensing practices have a pharmacist to support patients 93

94 Skin check clinics Safe sex packs for under 25 s and free condoms Supply POM medicines for minor ailments without GP input NHS blood tests (taking the blood sample). It is often a 3 week wait for blood tests at my doctor. Talks to support groups on subjects like smoking cessation, pregnancy, nutrition, drug abuse (for families who need advice), parentcraft, etc An appointment system Overseas, you go to the Pharmacist without prior appointment and are able to ask for advice and receive treatment for minor ailments and even inoculations - perhaps even change dressings or bandages in some cases. They can make a judgement if you need to seek emergency help or visit A&E. In some cases reassurance is all that is required. It saves GP time and reduces unnecessary visits to A&E. Chemists are usually open later in the evenings so less time taken off work due to treatment of minor ailments and GP surgery waiting time. Prescription delivery by Royal Mail to save car trips and car parking charges Provision for 10 minute parking Mobile pharmacy for annoyingly out of reach areas Health Promotion events such as one off testing days diabetes etc Whilst many respondents suggested ways of developing the current portfolio of pharmaceutical services there appeared to be a widespread lack of understanding of the full range that community pharmacies currently provide. 14% of respondents are not aware that they can return out-of-date, unused or unwanted medicines to a pharmacy (an essential pharmaceutical service) or GP dispensary. This illustrates a lack of awareness of the range of services available from pharmacies. The knock on effect of this lack of awareness is that 33% dispose of medicines inappropriately, with household rubbish, down the sink or stored in their home, with significant inherent risks to safety and the environment. 93% of respondents report that they are provided with sufficient information about their medication from their pharmacy/dispensing GP and 81.5% would ask their 94

95 pharmacist for advice about medicine prescribed by their GP. 76% of respondents rate confidence in their pharmacy as very high or high in terms of advice and knowledge with only 3% rating confidence as low or very low. Over 87% of respondents seek advice from a community pharmacy about over-the counter (OTC) medicines and nearly 60% generally obtain advice from the same pharmacy about OTC medicines. These responses demonstrate a high level of confidence in the advice provided from community pharmacies. However, nearly 8% of respondents did not know that their pharmacist can offer advice on general health issues, lifestyle and disease prevention e.g. stop smoking and healthy eating. Only 23% seek this advice from a community pharmacy. A significant proportion who commented stated that they obtained information from the internet, books, magazines and the press. This provides further evidence that there is a lack of awareness of the full range of services available from community pharmacies. Surprisingly, only 61% of respondents realise that their pharmacy has a consultation room available, where they can talk in private with the pharmacist. Is there a private consultation room available in your local pharmacy? Yes 61% No 10% Don't know 29.% Whilst some of the services below might not be expected to be recognised or understood by some respondents, there does again appear to be a lack of awareness of the range of services currently available. Only 60% of patients realise that they can access a medicines use review (MUR) at a pharmacy, a core advanced pharmaceutical service enabling them to talk to the pharmacist about their medication. When this lack of awareness is considered alongside the generally high level of 95

96 confidence in community pharmacy, this might indicate that there is great potential to develop the services provided by community pharmacies and increase the demand for services from the population and the contribution that community pharmacy can make to local healthcare. This could be partially addressed by co-ordinating a local awareness campaign. Which of the following services are you aware of that you can access from pharmacies Responses Supply of morning after pill 68% Stop smoking support 81% Chlamydia testing and treatment 29% Medicines Use Review to talk to your pharmacist about your medication 60% Treatment on the NHS for minor ailments (e.g. hay fever and constipation) 63% Disposal of needles/lancets 48% Supervised consumption (for treatment of substance misuse clients) 27% Needle exchange service (for treatment of substance misuse clients) 27% The point about lack of awareness and access to information was highlighted by some comments. Many expressed a need for more information about the range and availability of pharmaceutical services in Warwickshire. A representative sample is included below: Advertise services more widely and clearly the posters that are on display are bitty and untidy Pharmacies should clearly list and advertise, with readily available leaflets, the services on offer. It must be made easier to access information regarding pharmacies that are open out of usual hours. My biggest frustration is when my children are ill and I need a pharmacy and it s bank holiday. Information on the role and services offered by pharmacies should be better available and advertised nationally, regionally and locally. Might also be worth some posters to explain how medically trained 96

97 pharmacists actually are I think most people think they have a bit of specialist training but would be shocked to know how much training they have actually done Repeat prescription services. A few themes were consistent during the engagement process. Issues relating to obtaining repeat prescriptions from community pharmacies were common. Although many pharmacies now take a much more proactive role in managing repeat prescriptions than was usual a few years ago, his has clearly become a greater barrier to access from some patients. Although my prescriptions are ed through from my GP to the pharmacy and I am then contacted by text to say they are ready. I seem to wait ages because either they are not ready or they have lost them and then I wait while they spend considerable time looking for them. This happens quite frequently. Clients shouldn t have to wait so long for a medicine that is prescribed if possible some indication of busy times would be useful. Carry larger stock of prescription medicines it is not uncommon to wait a week for a repeat medicines to be supplied. Longest wait I have had is 3 months. Promises to phone when the medicine is in are not kept. Improve communications between surgery and pharmacy for repeat prescriptions. Repeat prescriptions should all be made up the day before they are due by the patient then the long wait you get would stop Pharmacies should tell you immediately if they have everything in stock as a return visit is frustrating as it may not be convenient.. Home delivery services (non-remunerated non-contractual services provided by many pharmacies) are clearly valued by those who have access to them. Those that do not have access often highlighted this as a service they would like to see introduced. Delivery of prescriptions from pharmacy to home address Delivery to those too ill to collect...disabled, chronically ill, lonely and vulnerable Extend delivery arrangements our pharmacy is excellent but does not deliver 97

98 Access to Pharmaceutical Services by locality The rural nature of parts of the county poses particular problems in accessing health and social care, whilst older people are more limited in their own personal mobility and transport options. The demand for care by an ageing population will require more support closer to people s homes and neighbourhoods where informal support can also be offered. Some areas of the health and social care system appear to close a on a Friday evening only to reopen at eight o clock the following Monday, unless it is a bank holiday! That experience is rare in all other aspects of our society where supermarkets may be open 24/7, and the rest of the service sectors work through the weekend. Some of the primary care services including community pharmacy are already looking to address this problem by opening for extended hours and offering support services i their communitiies. The summary of the location of current providers of pharmaceutical services and hours of service provision (Appendix 8a, 8b) illustrates access across the county. However, access must be considered in terms of the needs in individual localities. It would not be unreasonable to expect someone wishing to access a service to travel some distance at an unusual hour, but service users expect much greater convenience during normal working hours over the working week. It also needs to be taken into account that a certain distance of travel that is deemed acceptable in a rural sparsely populated area, might not be considered acceptable in a more densely populated urban district. Each locality was assessed to consider whether there is sufficient access and choice of pharmaceutical services using a template (Appendix 9) to collect information drawn from the PNA about each individual locality. A decision was then made about adequacy of current provision of pharmaceutical services and any apparent gaps and unmet needs were highlighted. 98

99 The national average number of community pharmacies is 21 per 100,000 people with this being varied across the country. The North West and Birmingham have the highest density (23.8 to 27.9 per 100,000 people), while Bath Gloucestershire Swindon & Wiltshire Area has a density of 19.2 to 20.6 per 100,000 people. Improving Health and patient care through Community Pharmacy Evidence resource Pack NHS England 2013 Easy access: 99 per cent of the population are within 20 minutes travel time of a community pharmacy with 96 per cent walking or by public transport. 84 per cent of adults visit a pharmacy each year, 78 per cent for health-related reasons. 1.6 million patients visit a pharmacy each day. Improving Health and patient Care through Community Pharmacy Evidence resource Pack NHS England 2013 This study examined accessibility of community pharmacies by walking distance and found that overall, 89.2% of the population is estimated to have access to a community pharmacy within a 20 min walk. For urban areas, that is 98.3% of the population, for town and fringe, 79.9% of the population; while for rural areas, 18.9% of the population. For areas of lowest deprivation 90.2% of the population have access to a community pharmacy within 20 min walk, compared to 99.8% in areas of highest deprivation highlighting that access is highest in the most deprived areas. The authors state that cost of driving and using public transport can be significant barriers to travel and, as such, may not give a true account of community pharmacy accessibility. Todd A, Copeland A, Husband A, et al. The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England,

100 North Warwickshire 62,000 population (OFNS) Headlines Smoking an estimated 10.4% of this population smokes (2012) Obesity 27.5% of adults are obese (2012) Physical Activity 56.6% of adults achieve the recommended levels of physical activity (2012) Life Expectancy For males is 78.7 years and 82.3 years for females ( ) Health in summary The health of people in North Warwickshire is varied compared with the England average. Deprivation is lower than average, however about 14.3% (1,500) of children live in poverty. Life expectancy for both men and women is similar to the England average. Living longer Life expectancy is not significantly different for people in the most deprived areas of North Warwickshire than in the least deprived areas. Child health In Year 6, 17.5% (115) of children are classified as obese. The rate of alcoholspecific hospital stays among those under 18 was 40.1*. This represents 5 stays per year. Levels of smoking at time of delivery are worse than the England average. Adult health In 2012, 27.5% of adults are classified as obese, worse than the average for England. The rate of alcohol related harm hospital stays was 484*, better than the average for England. This represents 310 stays per year. The rate of self-harm hospital stays was 189.9*. This represents 116 stays per year. The rate of smoking related deaths was 266*. This represents 93 deaths per year. Estimated levels of adult smoking are better than the England average. The rate of people killed and seriously injured on roads is worse than average. The rate of sexually transmitted 100

101 infections is better than average. Rates of statutory homelessness, violent crime, long term unemployment and drug misuse are better than average. Local priorities Priorities in North Warwickshire include mental health with a focus on dementia, smoking in pregnancy, and improving lifestyle behaviours. * rate per 100,000 population Summary of current level of access to NHS pharmaceutical services Thirteen pharmacies service this locality. There is access to one pharmacy from onwards from Monday to Saturday Four pharmacies are open by and all by Two pharmacies close at lunchtime on some weekdays but all remain open on other weekdays. This might be a source of confusion for some service users. There is good provision during the normal working day with all thirteen pharmacies remaining open until and eleven being open until (Mon- Fri). Two pharmacies are open on weekdays until or beyond in the evening. One late night pharmacy is open until (Mon-Sat) and later on some evenings. On Saturday, opening times are slightly later reflecting the change in demand, but eleven pharmacies are open by with five remaining open until 17.30, two until or beyond and one late night pharmacy until 22:00 On Sunday a service is provided by two pharmacies covering the hours from until Five dispensing GP practices also service this locality. Conclusion Taking into account the rural nature of this locality, pharmaceutical services are relatively easily to access from until from Monday to Friday. A service can be accessed somewhere in the locality from until at least A service is accessible all day on Saturday and from until on Sunday. 101

102 The population of 62,000 is serviced by thirteen pharmacies and five dispensing GPs (29 contractors per 100,000 population, including dispensing GPs) which is considered adequate with reference to local geography and size of locality. There is generally good access to services by road throughout the locality with the major residential concentrations all linked by major roads. Eight of the thirteen pharmacies providing pharmaceutical services to this locality belong to the Lloyds group and there is no supermarket pharmacy in the locality. There is no evidence however that this relatively limited range of contractors denies a sufficient level of choice to the public. The pharmaceutical service provided by community pharmacies in the locality is supplemented by five dispensing GP practices serving the more rural areas. The range of services provided is comprehensive including advanced and enhanced services in addition to the contractually required essential services. Current pharmaceutical service provision is adequately responding to the changing needs of the community within the confines of current commissioning opportunities. The priorities in this locality i.e. dementia, smoking in pregnancy, and improving lifestyle behaviours can be particularly well supported by the development of the Healthy Living Pharmacy programme and intelligent and innovative use of the MUR service. Opportunities presented to current contractors to develop their public health role to further support the HWB should be encouraged. The more rural areas of this locality benefit from the pharmaceutical service provided by dispensing doctors and the many collection and delivery services provided by community pharmacies. Cross-border availability of pharmaceutical services is significant in this locality. Public engagement has not highlighted any significant serious barriers to access in this locality. However all contractors are encouraged to consider the findings, feedback and general comments about service access in the locality that have been highlighted as part of this process. This will further enable contractors to meet the changing needs of their communities. A need for further specialist services to respond to local needs for specific populations or vulnerable groups is noted, and this would be complimented by a further role out of the HLP service. 102

103 Nuneaton & Bedworth 126,000 population (OFNS) Headlines Smoking 19.8% of the population smokes (2012) Obesity 27.0% of adults are obese (2012) Physical Activity 52.8% of adults achieve the recommended levels of physical activity (2012) Life Expectancy For males is 78.2 years and 82.6 years for females ( ) Health in summary The health of people in Nuneaton and Bedworth is varied compared with the England average. Deprivation is lower than average, however about 20.1% (4,900) children live in poverty. Life expectancy for men is lower than the England average. Living longer Life expectancy is 8.2 years lower for men and 6.0 years lower for women in the most deprived areas of Nuneaton and Bedworth than in the least deprived areas. Child health In Year 6, 20.8% (242) of children are classified as obese. The rate of alcohol specific hospital stays among those under 18 was 61.1*, worse than the average for England. This represents 17 stays per year. Levels of teenage pregnancy and smoking at time of delivery are worse than the England average. Adult health In 2012, 27.0% of adults are classified as obese. The rate of alcohol related harm hospital stays was 645*. This represents 787 stays per year. The rate of selfharm hospital stays was 271.6*, worse than the average for England. This represents 346 stays per year. The rate of smoking related deaths was 289*. This represents 188 deaths per year. The rate of people killed and seriously injured on roads is better than average. The rate of statutory homelessness is worse than average. The rate of drug misuse is better than average (* rate per 100,000 population) 103

104 Local priorities Priorities in Nuneaton and Bedworth include mental health, smoking in pregnancy, and improving lifestyle behaviours. Summary of current level of access to NHS pharmaceutical services Twenty seven pharmacies service this locality. There is access to one pharmacy from 06:00 onwards from Monday to Saturday At least eight pharmacies are open by and all by Between ten and fourteen pharmacies close at lunchtime on some weekdays. This might be a source of confusion for some service users. There is good provision during the normal working day with all pharmacies remaining open until and about half of these until (Mon-Fri). Four pharmacies are open on weekdays until or beyond in the evening. One late night pharmacy (two on Friday) is open until (Mon-Fri). On Saturday a service is available from All pharmacies open on Saturday by 09.00, with over half remaining open beyond Three remain open until and one late night pharmacy until midnight. On Sunday a service is provided by five pharmacies covering the hours from until midnight. Conclusion Pharmaceutical services are relatively easily to access from until from Monday to Friday. A service can be accessed somewhere in the locality from until at least A service is accessible all day on Saturday and Sunday. The population of 126,000 is serviced by twenty seven pharmacies (21 contractors per 100,000 population, which is considered adequate with reference to local geography and size of locality. There is generally good access to services by road throughout the locality with the major residential concentrations all linked by major roads. There is a good mix of pharmacy contractors in this locality including independents, small multiples, large multiples and supermarkets. The range of services provided is comprehensive including advanced and enhanced services in addition to the contractually required essential services. 104

105 Current pharmaceutical service provision is adequately responding to the changing needs of the community within the confines of current commissioning opportunities. The priorities in this locality i.e. mental health, smoking in pregnancy and improving lifestyle behaviours can be particularly well supported by the development of the Healthy Living Pharmacy programme and intelligent and innovative use of the MUR service. Opportunities presented to current contractors to develop their public health role to further support the HWB should be encouraged. The locality benefits from the many collection and delivery services provided by community pharmacies. Cross-border availability of pharmaceutical services is significant in this locality. Public engagement has not highlighted any significant serious barriers to access in this locality. However all contractors are encouraged to consider the findings, feedback and general comments about service access in the locality that have been highlighted as part of this process. This will further enable contractors to meet the changing needs of their communities. A need for further specialist services to respond to local needs for specific populations or vulnerable groups is noted, and this would be complimented by a further role out of the HLP service. 105

106 Warwickshire North CCG Warwickshire North CCG comprises of the Boroughs of North Warwickshire and Nuneaton & Bedworth. The combined population of the area is 187,500 (mid-2011 estimate), 34% of the total Warwickshire population. Compared with the rest of the county Warwickshire North CCG is expected to experience considerably less population growth, with North Warwickshire Borough projected to see the smallest population growth in Warwickshire. For some age groups, North Warwickshire Borough is expected to experience a negative population growth during the period This could impact on the local labour market and local economy of Borough. Health inequalities are apparent within the CCG as life expectancy in the area is lower than the Warwickshire average whilst in Nuneaton & Bedworth Borough it is significantly worse than the average for England. Data suggests an under diagnosis or under recording of Coronary Heart Disease (CHD) within Warwickshire North, yet the CHD rate is still significantly higher than that for England. Further inequalities are prominent as the CCG has high identification of people on the diabetes disease register, but there is considerable variation across GP Practices. There are significantly higher levels of patients across Warwickshire North who die in their own homes: 22.8% compared to 20.3% nationally. In terms of healthy lifestyles, the CCG has a significantly high prevalence of obesity when compared with the national average (for both children and adults). The number of alcohol related hospital admissions has increased in the last five years in both men and women and smoking remains a high priority for the NHS within Warwickshire North. 106

107 Rugby 101,000 population (OFNS) Headlines Smoking 16.9% of the population smokes (2012) Obesity 20.4% of adults are obese (2012) Physical Activity 54.0% of adults achieve the recommended levels of physical activity (2012) Life Expectancy For males is 80.2 years and 83.7 years for females ( ) Health in summary The Rugby locality falls under the responsibility of the Coventry and Rugby CCG. The health of people in Rugby is varied compared with the England average. Deprivation is lower than average, however about 13.7% (2,500) children live in poverty. Life expectancy for men is higher than the England average. Life expectancy is 7.4 years lower for men and 6.3 years lower for women in the most deprived areas of Rugby than in the least deprived areas. In Year 6, 16.7% (164) of children are classified as obese. The rate of alcoholspecific hospital stays among those under 18 was 30.2*. This represents 7 stays per year. Levels of smoking at time of delivery are worse than the England average. In 2012, 20.4% of adults are classified as obese. The rate of alcohol related harm hospital stays was 627*. This represents 610 stays per year. The rate of smoking related deaths was 232*, better than the average for England. This represents 128 deaths per year. The rate of sexually transmitted infections is better than average (* rate per 100,000 population) The Borough is projected to experience the highest levels of population growth within Warwickshire, with an overall increase of 30% between the period of In terms of Positivity measures, Rugby Borough has 2 Super Output Areas (SOAs) 107

108 which rank within the county s top 5 SOAs and where residents feel nothing can be done to improve their lives. One of which, Rugby Town Central, is also within the top 10% most deprived SOAs nationally. There are also 3 SOAs in Rugby which rank in the top 5 SOAs in Warwickshire most likely to feel improvements can occur - this highlights the level of diversity across the Borough. Within the Borough, the rate of violent crime, long term unemployment and drug misuse are lower than the England average. In the last 10 years, all cause mortality rates in Rugby Borough have fallen and early death rates from cancer, heart disease and stroke show no clear trend and are similar to the England average. Local priorities Priorities in Rugby include addressing alcohol misuse, smoking in pregnancy, falls prevention and tackling obesity. Summary of current level of access to NHS pharmaceutical services Nineteen pharmacies service this locality. There is access to one pharmacy from onwards from Monday to Saturday (and on some mornings). Eleven pharmacies are open by and all by Nine pharmacies close at lunchtime on weekdays. There is good provision during the normal working day with eighteen pharmacies remaining open until (Mon-Fri). Four pharmacies are open on weekdays until or beyond in the evening. Two late night pharmacies (three on Friday) remain open until or (Mon-Fri). On Saturday a service is available from Eighteen pharmacies open on Saturday, five by and all by Ten pharmacies close at lunchtime and one reopens with seven remaining open beyond and three until On Sunday a service is provided by four pharmacies covering the hours from until Three dispensing GP practices also service this locality. 108

109 Conclusion Pharmaceutical services are relatively easy to access from until from Monday to Friday. A service can be accessed somewhere in the locality from until at least A service is accessible all day on Saturday and from until on Sunday. The population of 101,000 is serviced by nineteen pharmacies and three dispensing GPs (22 contractors per 100,000 population) which is considered adequate with reference to local geography and size of locality. There is generally good access to services by road throughout the locality with the major residential concentrations all linked by major roads. There is a good mix of pharmacy contractors in this locality including independents, small multiples, large multiples and supermarkets. The pharmaceutical service provided by community pharmacies in the locality is supplemented by 3 dispensing GP practices serving the more rural areas. The range of services provided is comprehensive including advanced and enhanced services in addition to the contractually required essential services. Current pharmaceutical service provision is adequately responding to the changing needs of the community within the confines of current commissioning opportunities. The priorities in this locality i.e. alcohol misuse, smoking in pregnancy, falls prevention and tackling obesity can be particularly well supported by the development of the Healthy Living Pharmacy programme and intelligent and innovative use of the MUR service. Opportunities presented to current contractors to develop their public health role to further support the HWB should be encouraged. The more rural areas of this locality benefit from pharmaceutical service provided by dispensing doctors and the many collection and delivery services provided by community pharmacies. Cross-border availability of pharmaceutical services is significant in this locality. A small number of respondents to the public engagement process expressed a need for a 24/7 and out-of-hours service in Rugby. These views have been considered but it has been concluded that overall the current spread of contractor opening hours is adequate and does not present a barrier to access in this 109

110 locality. All contractors are encouraged to consider the findings, feedback and general comments about service access in the locality that have been highlighted as part of this process. This will further enable contractors to meet the changing needs of their communities. A need for further specialist services to respond to local needs for specific populations or vulnerable groups is noted, and this would be complimented by a further role out of the HLP service. 110

111 Stratford-upon-Avon District 121,0000 population (OFNS) Headlines Smoking 19.8% of the population smokes (2012) Obesity 21.4% of adults are obese (2012) Physical Activity 58.4% of adults achieve the recommended levels of physical activity (2012) Life Expectancy For males is 81.0 years and 84.9 years for females ( ) Health in summary The health of people in Stratford-on-Avon is generally better than the England average. Deprivation is lower than average, however about 10.1% (2,100) children live in poverty. Life expectancy for both men and women is higher than the England average. Living longer Life expectancy is 3.7 years lower for men and 5.9 years lower for women in the most deprived areas of Stratford-on- Avon than in the least deprived areas. Child health In Year 6, 13.6% (153) of children are classified as obese, better than the average for England. The rate of alcohol specific hospital stays among those under 18 was 51.4*.This represents 12 stays per year. Levels of smoking at time of delivery are worse than the England average. Levels of teenage pregnancy and GCSE attainment are better than the England average (* rate per 100,000 population) Adult health In 2012, 21.4% of adults are classified as obese. The rate of alcohol related harm hospital stays was 518*, better than the average for England. This represents 661 stays per year. The rate of self-harm hospital stays was 114.2*, better than the average for England. This represents 125 stays per year. The rate of smoking related deaths was 202*, better than the average for England. This represents 169 deaths per year. Rates of sexually transmitted infections and TB are better than 111

112 average. Local priorities Priorities in Stratford-on-Avon include addressing alcohol misuse, smoking in pregnancy, and tackling obesity. Summary of current level of access to NHS pharmaceutical services Eighteen pharmacies service this locality. There is access to one pharmacy from onwards from Monday to Friday. Four pharmacies are open by and all by Between three and nine pharmacies close at lunchtime on different weekdays which might be a source of confusion for some service users. There is good provision during the normal working day with seventeen pharmacies remaining open until (Mon-Fri). Three pharmacies are open on weekdays until or beyond in the evening. One late night pharmacy remains open until (Mon-Fri). On Saturday a service is available from Seventeen pharmacies open on Saturday, all by Six pharmacies close at lunchtime and do not reopen with nine remaining open until or beyond and one until On Sunday a service is provided by five pharmacies covering the hours from until Eleven dispensing GP practices also service this locality. Conclusion Pharmaceutical services are relatively easily to access from until from Monday to Friday. A service can be accessed somewhere in the locality from until at least A service is accessible all day on Saturday and from until on Sunday. The population of 121,000 is serviced by sixteen pharmacies and eleven dispensing GPs (22 contractors per 100,000 population) which is considered adequate with reference to local geography and size of locality. There is good access to services by road throughout the locality with the major residential concentrations all linked by major roads. 112

113 There is a good mix of pharmacy contractors in this locality including independents, small multiples, large multiples and supermarkets. The pharmaceutical service provided by community pharmacies in the locality is supplemented by eleven dispensing GP practices serving the more rural areas. The range of services provided is comprehensive including advanced and enhanced services in addition to the contractually required essential services. Current service provision is adequately responding to the changing needs of the community. The priorities in this locality i.e. alcohol misuse, smoking in pregnancy, and tackling obesity can be particularly well supported by the development of the Healthy Living Pharmacy programme and intelligent and innovative use of the MUR service. Opportunities presented to current contractors to develop their public health role to further support the HWB should be encouraged. The more rural areas of this locality benefit from pharmaceutical service provided by dispensing doctors and the many collection and delivery services provided by community pharmacies. Cross-border availability of pharmaceutical services is significant in this locality. Public engagement has not highlighted any significant serious barriers to access in this locality. However all contractors are encouraged to consider the findings, feedback and general comments about service access in the locality that has been highlighted as part of this process. This will further enable contractors to meet the changing needs of their communities. A need for further specialist services to respond to local needs for specific populations or vulnerable groups is noted, and this would be complimented by a further role out of the HLP service. 113

114 Warwick District 139,000 population (OFNS) Headlines Smoking 18.6% of the population smokes (2012) Obesity 15.8% of adults are obese (2012) Physical Activity 55.3% of adults achieve the recommended levels of physical activity (2012) Life Expectancy For males is 80.4 years and 84.7 years for females ( ) Health in summary The health of people in Warwick is generally better than the England average. Deprivation is lower than average, however about 11.4% (2,600) children live in poverty. Life expectancy for both men and women is higher than the England average. Living longer Life expectancy is 7.8 years lower for men and 7.7 years lower for women in the most deprived areas of Warwick than in the least deprived areas. Child health In Year 6, 13.5% (154) of children are classified as obese, better than the average for England. The rate of alcoholspecific hospital stays among those under 18 was 42.7*. This represents 11 stays per year. Levels of smoking at time of delivery are worse than the England average. Levels of teenage pregnancy are better than the England average. Adult health In 2012, 15.8% of adults are classified as obese, better than the average for England. The rate of alcohol related harm hospital stays was 580*, better than the average for England. This represents 765 stays per year. The rate of self-harm hospital stays was 151.3*, better than the average for England. This represents 214 stays per year. The rate of smoking related deaths was 233*, better than the average for England. This represents 176 deaths per year. Rates of hip fractures and 114

115 sexually transmitted infections are better than average. The rate of statutory homelessness is worse than average (* rate per 100,000 population) Local priorities Priorities in Warwick include addressing alcohol misuse, smoking in pregnancy, and tackling obesity. Summary of current level of access to NHS pharmaceutical services Twenty eight pharmacies service this locality. There is access to one pharmacy from onwards from Monday to Saturday. Half of the pharmacies are open by and all by Between nine and eleven pharmacies close at lunchtime on different weekdays which might be a source of confusion for some service users. There is good provision during the normal working day with 82% of pharmacies remaining open until (Mon-Fri). Three pharmacies are open on weekdays until or beyond in the evening. One late night pharmacy remains open until (Mon-Fri). On Saturday a service is available from Twenty three pharmacies open on Saturday, all by Eight pharmacies close at lunchtime and do not reopen with twelve remaining open until or beyond and one until On Sunday a service is provided by five pharmacies covering the hours from until Three dispensing GP practices also service this locality. Conclusion Pharmaceutical services are relatively easily to access from until from Monday to Friday. A service can be accessed somewhere in the locality from until at least A service is accessible all day on Saturday and from until on Sunday. The population of 139,000 is serviced by twenty eight pharmacies and three dispensing GPs (22 contractors per 100,000 population) which is considered adequate with reference to local geography and size of locality. There is good access to services by road throughout the locality with the major 115

116 residential concentrations all linked by major roads. There is a good mix of pharmacy contractors in this locality including independents, small multiples, large multiples and supermarkets. The pharmaceutical service provided by community pharmacies in the locality is supplemented by three dispensing GP practices serving the more rural areas. The range of services provided is comprehensive including advanced and enhanced services in addition to the contractually required essential services. Current pharmaceutical service provision is adequately responding to the changing needs of the community within the confines of current commissioning opportunities. The priorities in this locality i.e. alcohol misuse, smoking in pregnancy, and tackling obesity can be particularly well supported by the development of the Healthy Living Pharmacy programme and intelligent and innovative use of the MUR service. Opportunities presented to current contractors to develop their public health role to further support the HWB should be encouraged. The more rural areas of this locality benefit from pharmaceutical service provided by dispensing doctors and the many collection and delivery services provided by community pharmacies. Cross-border availability of pharmaceutical services is significant in this locality. A small number of respondents to the public engagement process expressed a need for a 24/7 service in Warwick and poor access to a service during the lunch hour in Kenilworth and on Saturday afternoons.. These views have been considered but it has been concluded that overall the current spread of contractor opening hours is adequate and does not present a barrier to access in this locality. All contractors are encouraged to consider the findings, feedback and general comments about service access in the locality that has been highlighted as part of this process. This will further enable contractors to meet the changing needs of their communities. A need for further specialist services to respond to local needs for specific populations or vulnerable groups is noted, and this would be complimented by a further role out of the HLP service. 116

117 NHS South Warwickshire CCG South Warwickshire CCG area is comprised of the Stratford-on-Avon and Warwick Districts. The combined population of the Districts is 258,500 (mid 2011 estimate), 47% of the total Warwickshire population, making it the largest CCG in the County. South Warwickshire CCG is expected to experience some of the highest rates of population growth within the county, with Stratford-on-Avon District s population projected to see the second highest levels of growth, behind Rugby Borough. The highest rates of growth are among the 65 and over age group and in addition to this; Stratford-on-Avon District has the highest dependency ratio within Warwickshire, explaining the need for focus to be on caring for the frail and elderly. The health of the population is generally better than the England average and life expectancy in both Stratford-on-Avon District and Warwick District is higher than the national average. Despite this, over the last 12 months the CCG has required the highest total annual expenditure within the Public Health budget, amounting to 47% of the total budget. Priorities within the CCG consist of improvements to cancer screening, preventing falls, increasing wellbeing factors such as mental health, and healthy lifestyle indicators such as obesity. 117

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