1.2 This application is being made for the following reasons:

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1 REF: SHA/17993 APPEAL AGAINST KENT AND MEDWAY AREA TEAM, NHS COMMISSIONING BOARD ("NHS ENGLAND") DECISION TO REFUSE AN APPLICATION BY MR G PHILLIPS FOR INCLUSION IN THE PHARMACEUTICAL LIST OFFERING UNFORESEEN BENEFITS UNDER REGULATION 18 WITHIN 200M OF THE PROPOSED WAITROSE DEVELOPMENT AND NEW BUTCHERY SURGERY, DOVER ROAD, SANDWICH, KENT, CT13 1 Trevelyan Square Boar Lane Leeds LS1 6AE Tel: Fax: fhsau@nhsla.com 1 The Application By undated application received 24 th October 2014, Mr G Phillips ( the Applicant ) applied to NHS CB (Kent and Medway Area Team) ( NHS England ) for inclusion in the pharmaceutical list offering unforeseen benefits under Regulation 18 within 200m of the proposed Waitrose development and new Butchery Surgery, Dover Road, Sandwich, Kent, CT13. In support of the application it was stated: 1.1 The nearest existing pharmacy is located more than 500m away from the proposed site and therefore Regulation 31 is not applicable. 1.2 This application is being made for the following reasons: Planning permission has recently been granted (September 2014) for a new Waitrose Supermarket, GP surgery and pharmacy premises at the proposed location As a result of plans being put forward for this new development, it has become apparent that there is substantial local support for an additional pharmacy in Sandwich It is proposed that the Butchery Surgery will relocate a significant distance from its current town centre location. As a result, patients attending the surgery and requiring pharmaceutical services will be faced with an additional journey to access the existing pharmacy The opening of a new major supermarket will bring additional people into Sandwich to access services. Provision of an accessible community pharmacy would secure improvements and better access to pharmaceutical services for the town.

2 Residential development in Sandwich is ongoing, creating additional demand for pharmaceutical services. 1.3 As none of this information was included in the Eastern & Coastal Kent Pharmaceutical Needs Assessment published in February 2011, or subsequent supplementary statements, this application is being made to provide 'unforeseen benefits' in accordance with regulation 18 of the Regulations. 1.4 General information 1.5 Sandwich is a historic town located close to the East Kent coast. The parish population was around 5,000 people at the time of the 2011 census but its 'catchment' population is significantly larger as the town serves the needs of large number of people living in nearby villages as well as a large number of visitors throughout the year. This is evidenced by the extent and range of other facilities provided within the town which include: Two medical practices A large Co-Op supermarket Numerous public houses and restaurants A wide range of independent and national retailers A railway station A holiday park Various community facilities Four schools Two world-class golf courses 1.6 The demand for further facilities to be provided for residents and visitors has resulted in advanced plans being put into place for the new Waitrose store, to be located south of the railway line, some distance from the town centre. The need for a new supermarket in the town was identified by consultants to Dover District Council in 2012 and planning permission has recently been granted subject to final approval by the Secretary of State. 1.7 Comments made by councillors considering the Waitrose planning application included the following: Cllr Jeremy Watts said: "This development would bring Deal people into Sandwich and might encourage them to shop in our local shops "There's quite a strong body of public opinion in favour of this and not just for the supermarket but for the doctors' surgery and the muchneeded pharmacy."

3 3 1.8 The Applicant has included a small selection of the 300+ comments made by members of the public in response to the planning application in appendix A. Several of these make specific mention of the need for an additional pharmacy. 1.9 Local population and healthcare needs 1.10 The resident population of Sandwich is significantly more elderly than the England average. The average (mean) age of the population, based on Middle Super Output Area Dover 002 (which encompasses the town) is 45.0 compared to 39.3 for England as a whole according to the 2011 census The population aged over 65 is 24.3% compared to 16.4% across England and, perhaps related to this statistic, the number of people whose activities are limited by illness or disability is 21.3% versus the England average of 17.6% The Applicant believes that, given the comparatively high level of older people and those with ill health and/or disability, the pharmaceutical needs of residents are greater than might ordinarily be expected in a town of this size Existing healthcare provision 1.14 Pharmaceutical services in Sandwich are currently provided by Boots located on Market Street. The next nearest pharmacies, should patients wish to exercise their right for choice, are located more than 3 miles away in Eastry (Eastry Pharmacy) or Ash (Boots) Medical services are provided by two practices, Market Place Surgery (which has a branch surgery in Eastry) and The Butchery Surgery. The combined patient list size (including the branch surgery) is around 13,100 patients The Applicant has included a map in appendix B showing the location of existing providers in Sandwich in relation to the application site The proposed site 1.18 The proposed site is located to the south of the town on the opposite side of the railway from the town centre. It is situated on Dover Road which provides the main route into the town for those travelling from the south There is a significant residential population in the south west part of the town but more importantly the new supermarket will serve the needs of all local residents and those from further afield in surrounding villages and the town of Deal The site will benefit from extensive parking provision which will address the difficulties frequently encountered by those driving into Sandwich who wish to access existing facilities The need for additional pharmaceutical services 1.22 Residential Development

4 The town is subject to ongoing residential development at Willowbank to the north east of the town centre There are also proposals to construct an additional 500+ new homes at Discovery Park, the former Pfizer site to the north of the town These developments will grow the population of the town further (with another 1,500-2,000 residents) and add to the existing pressure on pharmaceutical services within the town Existing pharmaceutical services 1.27 As already highlighted, there is significant evidence that there is discontent within the town in respect of the service provided by Boots. Respondents to the planning application have cited a number of issues such as: Poor stock levels Difficulties with parking close to the pharmacy Long waiting times Inefficiency 1.28 When viewed in light of the planned relocation of one of the town's surgeries, further residential development and the distance required to access an alternative pharmacy, in the Applicant s opinion, existing pharmaceutical services do not properly meet the needs of the local population Information in support of the application 1.30 The Applicant is required by the NHSCB to address two specific questions in this supporting information: (i) Please describe the unforeseen benefit(s) that you are offering to secure and how it will secure improvements or better access to pharmaceutical services, or pharmaceutical services of a specified type in the HWB's area". (ii) Please explain how you intend to secure the unforeseen benefit(s) The Applicant has addressed these matters by setting out in further details below: 1.32 It is worth noting that the amendments to the 2013 Regulations, which came into force in April 2014, make an important change to Regulation 18(2)(b) as highlighted below: (b) whether, notwithstanding that the improvements or better access were not included in the relevant pharmaceutical needs assessment, it is satisfied that, having regard in particular to the desirability of

5 5 (i) there being a reasonable choice with regard to obtaining pharmaceutical services in the area of the relevant HWB (taking into account also the NHSCB's duties under sections 13I and 13P of the 2006 Act (b) (duty as to patient choice and duty as respects variation in provision of health services)), (ii) people who share a protected characteristic having access to services that meet specific needs for pharmaceutical services that, in the area of the relevant HWB, are difficult for them to access (taking into account also the NHSCB 's duties under section 13G of the 2006 Act(c) (duty as to reducing inequalities)), or (iii) there being innovative approaches taken with regard to the delivery of pharmaceutical services (taking into account also the NHSCB's duties under section 13K of the 2006 Act (a) (duty to promote innovation)), granting the application would confer significant benefits on persons in the area of the relevant HWB which were not foreseen when the relevant pharmaceutical needs assessment was published; 1.33 The implication is NHS England no longer has to have regard to all three of these matters. If it finds that one of these one of these points apply then it may grant the application Securing better access and choice 1.35 As discussed earlier there is only one existing pharmacy in Sandwich and no dispensing doctors. Given the distance to the next nearest pharmacies, there is no reasonable choice for residents of in terms of existing pharmaceutical services There is evidence that many patients are not satisfied with the current level of access to services. It is the Applicant s view that this is largely the result of the lack of patient choice. Where there is no competition then there is little incentive for existing providers to improve services The Applicant s proposed pharmacy will improve access to pharmaceutical services in a number of ways: The extended hours will ensure that patients are able to access a pharmacy later in the evening from Monday to Friday as well as having access to a pharmacy on Sundays. The nearest pharmacy currently open on a Sunday is Paydens in Deal, some 6 miles away by road There will be extensive free parking at the site, including disabled parking. This is particularly important when the town is busy as roads are congested and parking is difficult. Parking and congestion problems are increased during the summer months due to the influx of tourists to the town.

6 As there will be a major new supermarket in the area, many residents of the town, as well as visitors, will access the site as part of their daily lives The range of pharmacy services provided will be unrivalled within the area. This will ensure that there are innovative services available to local people for which they would currently have to travel long distances Services 1.39 Given the relatively elderly population of the town, this patient group is of particular relevance. Providing improved access for elderly people (which is a group with a protected characteristic) will ensure that pharmaceutical services are more easily available As highlighted in the application the Applicant would be prepared to offer any pharmaceutical service commissioned either locally or nationally. The Applicant will commit to achieving the necessary accreditation required to provide these services and will install a fit for purpose consultation room. Furthermore the Applicant is aware that they will be obliged to offer all of the services included on their application form should these be commissioned within three years of an application being approved The Applicant s award-winning company has a much-envied reputation in respect of providing pharmacy services and their Broadstairs Pharmacy, Pierremont, is known throughout the area for providing an extensive range of innovative and high quality pharmacy services The Applicant s group of 9 pharmacies has won virtually every major pharmacy award in recent years and in some cases more than once. These include the C&D awards, RPS/PJ pharmaceutical care awards, Alliance Healthcare and Alphega group awards plus many more In addition the Applicant has achieved local (non-pharmacy awards) such as the Argent Press "Business Person of the Year" and "Retailer of the Year" The Applicant has strong academic links with several schools of pharmacy including Medway and Nottingham. The Applicant s Diabetes paper was published in a high-impact academic journal with outstanding results. The Applicant is also working with Nottingham School of Pharmacy to help them introduce the new 5yr, integrated degree In the event of the application being approved it would be the Applicant s intention to offer the local residents the benefit of their expert advice and services which would have a positive impact on the health of the community If this application is approved the Applicant will be applying to apply for Healthy Living Status in line with their other pharmacies. "Research ready pharmacy" accreditation is currently being implemented within the existing

7 7 group of pharmacies and the Applicant would intend to add this branch to that list The Applicant believes that they are exceptionally well placed to provide a service which not only addresses the current gaps in service but which will ensure fit-for-the-future pharmacy services are provided for the people of Sandwich Conclusion 1.49 As can be seen from the evidence in this document Sandwich is a growing town which serves the needs of a large population. It has an excellent range of facilities which cater for their everyday needs However, in the Applicant s opinion, pharmacy provision does not meet the needs of this growing number of residents and the large visiting population. Residents who wish to exercise their right to choice have to travel a significant distance and those wishing to access a pharmacy after 6.30pm or on a Sunday have no access at all without making an unreasonably long journey The Applicant s proposed pharmacy will offer residents a highly accessible pharmacy and provide much needed choice. The Applicant is confident that their service is second to none and their expertise will ensure that provision within the town is fit for the future for many years to come The Applicant therefore urges NHS England to approve this application accordingly. 2 The Decision NHS England considered and decided to refuse the application. The decision letter dated 31 st March 2015 states: 2.1 NHS England has considered the above application and [is] writing to notify [the Applicant] that it has been refused. 2.2 NHS England had received three applications for consideration under regulation 18 of the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013, as amended offering to secure improvements or better access to pharmaceutical services or certain services within the South Kent Coast Health and Wellbeing Board (HWB) area that were not included in the Eastern and Coastal Kent Pharmaceutical Needs Assessment (PNA). 2.3 The PSRC had before it the applications, the responses to the notification exercise, and the comments received on those responses. On the basis of this information, the PSRC considered it was not necessary to hold an oral hearing. 2.4 The PSRC was satisfied that there were no other contractors (who may or may not be the applicants) currently providing pharmaceutical services from the premises to which the applications relate, or from adjacent premises. The Committee, therefore, did not have grounds to refuse the applications by virtue of regulation 31.

8 8 2.5 The PSRC was satisfied that the proposed best estimate locations were not within an LPS designation. The Committee therefore did not have grounds to refuse the application by virtue of regulation Regulation 18(2)(a) 2.7 The Committee considered whether the granting of these applications would cause significant detriment to the proper planning, or the arrangements in place for, the provision of pharmaceutical services in the HWB s area and decided that it did not. 2.8 In reaching this decision the Committee noted that the Area Team had no specific plans with regard to the provision of pharmaceutical services within the South Kent Coast Health and Wellbeing Board s area. The Committee therefore did not have grounds to refuse the applications by virtue of regulation 18(2)(a). 2.9 Regulation 18(2)(b) 2.10 The Committee felt that granting the applications would not confer significant benefits on persons that were not foreseen when the PNA was published The PSRC was satisfied that there was already reasonable choice with regard to obtaining pharmaceutical services in the area The Committee also noted that the proposed premises for both the medical centre (relocation of the Butchery Surgery) and pharmacy were not built yet and were due to be contained within the new Waitrose development, for which planning permission has been granted. However, the GP surgery has only received stage one approval (of three) for its business case. Stage two is expected within the next couple of months and basic draft plans have been drawn up. The PSRC therefore felt that the applications were relying somewhat on the assumption that the new GP surgery would definitely come to fruition Manor Pharmacy demonstrated limited benefits but failed to provide sufficient information regarding what unforeseen benefits they will address There was no reference to improving access by specific patient groups or those with a protected characteristic, apart from mentioning the elderly this is not regarded as a protected characteristic, the applicant has to refer to a particular age or range of ages The application did not demonstrate any innovative approach to delivery of services On the basis of these recommendations, the PSRC refused the application.

9 9 3 The Appeal In a letter to the Family Health Services Appeal Unit of the NHS Litigation Authority ( the Appeal Unit ), dated 30 th April 2015, the Applicant appealed against NHS England's decision. The grounds of appeal are: 3.1 The Applicant wishes to appeal against this decision to refuse the application for the following reasons: 3.2 In considering Regulation 18(2)(b)(i) the PSRC stated that it was satisfied that there was already reasonable choice without explaining its rationale for coming to this conclusion. Given that there is only one pharmacy in Sandwich (and therefore no choice) the Applicant can only assume that the committee had regard to pharmacies elsewhere. However the Applicant does not believe that the committee properly considered whether the relevant population is able to reasonably access these pharmacies. In the Applicant s opinion it is not. Where pharmacies located some distance away are not reasonably accessible then they do not provide additional choice. 3.3 In respect of 18(2)(b)(ii) the PSRC has criticised the Applicant s failure to refer to a particular age or range of ages in respect of people with protected characteristics. The committee acknowledged that age is a protected characteristic yet appear to have missed the Applicant s reference to the high proportion of the population over the age of 65 within the supporting document provided. The Applicant believes this point was clearly made yet misunderstood by the committee. 3.4 In coming to the conclusion that the application did not demonstrate any innovative approach to delivery of services the committee has paid no regard to the information provided in the application regarding the extended range of services proposed and the Applicant s track record in delivering these services. 3.5 The PSRC placed undue weight on the fact that plans for the new GP surgery have not been fully signed off in making its decision. In the Applicant s opinion, the weight of evidence in respect of poor existing provision, increasing population and the impact of the new supermarket decision are grounds alone for approving the application. Furthermore, given the challenges associated with accessing the existing Butchery Surgery premises, the grant of stage one approval for the business case and the grant of planning permission for new premises, it is highly likely that the new surgery will open. 3.6 The Applicant has provided further detail below in respect of their grounds for appeal as well as additional information to assist the Appeal Unit Committee in considering this matter. The Applicant s comments are set out in accordance with the tests in regulation Regulation 18 (1)

10 The fundamental test set out in Regulation 18(1) is whether granting the application would secure improvements or better access to pharmaceutical services in the area of the relevant HWB. 3.9 To answer this question firstly we need to establish who might benefit from a pharmacy in the proposed location. As set out in the application, the reliant population in this case is significantly more than the 5,000 population of the town itself. The patient population of the two surgeries in the town is in excess of 13,000 and whilst some of these may attend the branch surgery in Eastry, the vast majority attend the Sandwich surgeries Sandwich is the main commercial centre between Deal and Ramsgate on the Kent coast and is a destination for shopping and other services for residents of surrounding small towns and villages, as well as a very significant number of tourists and employees. Given the range of services to be provided at the proposed pharmacy and the elderly nature of the population, in the Applicant s opinion it is clear that a substantial number of people would benefit from the proposed pharmacy Secondly the Applicant needs to establish whether granting this application will secure improvements to the pharmaceutical services currently available to this population. The Applicant has described within their application how the failure of the existing pharmacy in Sandwich to properly meet the needs of local people has resulted in shortfalls in the quality and range of pharmaceutical services available that would be addressed if this application is granted And thirdly we need to establish whether granting the application would result in better access to pharmaceutical services for this reliant population. It is the Applicant s opinion that the access to pharmaceutical services is poor not only in terms of the geographical limitations but also in respect of the range of services available to residents and existing pharmacy opening hours Regulation 18(2)(a) 3.14 None of the parties who commented on the application provided any evidence to suggest that granting the application would result in significant detriment to the proper planning, or the arrangements in place for, the provision of pharmaceutical services in the area of the HWB The Applicant also notes that NHS England had regard to its future plans when considering the application and found that there were no grounds to refuse it by virtue of regulation 18(2)(a). As this matter appears to be uncontentious, the Applicant proposes to add no further comments at this stage other than to reserve the right to comment later should any party seek to provide any evidence of detriment Regulation 18(2)(b)(i) Choice

11 The PSRC did not explain, in any detail, why it came to the conclusion that there was already reasonable choice with regard to obtaining pharmaceutical services in the area so the Applicant can only speculate It may be that the committee formed the view, as it is entitled to do, that in this instance, the sole pharmacy in the town provides reasonable choice for residents and visitors. To come to this conclusion, it would have had to have satisfied itself that: The pharmacy is highly accessible such that anybody in Sandwich who requires pharmaceutical services would not have difficulties accessing them The opening hours provided by the pharmacy fully meet the requirements of people living in and visiting the town In respect of the first of these questions the Applicant refers to the statistic on car ownership provided by Boots in their letter of 5 th January in response to the application. They state that car ownership is extremely high in this area, 81.9% of residents in Sandwich have access to one or more cars. It is reasonable to assume, therefore, that most people rely on their cars to access services, particularly those living outside the town However, travelling into Sandwich by car is not straightforward. The town is plagued by congestion problems as a result of heavy traffic constantly passing along the narrow medieval roads to the extent that residents have tried to take matters into their own hands. In summer 2014 Lorrywatch was set up to gather evidence of the scale of the problem. A page from the website has been included in appendix A which is selfexplanatory. Furthermore there is a one way system around the town centre which can be very confusing for visitors in particular, who would find it very difficult to find the pharmacy let alone park near to it if they did not know the town well Parking in the town, especially in the tourist season, can be very difficult and, even if a space can be found in one of the car parks, the journey to the pharmacy is still likely to be more than 250m, even for disabled drivers given the highly limited availability of disabled parking spaces close to the pharmacy. For a wheelchair user, the journey would be particularly difficult taking into account the narrow pavements and areas of cobblestones It is also worth noting that the nearest bus stop to the pharmacy is also in excess of 200m away so bus users with mobility difficulties will face a similar journey along narrow streets with limited provision of pavements, as well as having to cross busy roads which are often clogged up with traffic It is also relevant, of course, that one of the reasons car ownership is relatively high is that Sandwich caters for a large rural area too. Given the elderly nature of the population in general it is reasonable to assume that, with the exception of residents living within the town centre, very few patients would ordinarily walk to the pharmacy so most will access by car or public transport.

12 It is the Applicant s opinion that the difficulties accessing the pharmacy in Sandwich by car, bus and on foot are such that it cannot be said that the sole pharmacy offers reasonable choice In respect of the second question above, whilst the Applicant notes that the pharmacy opens for six days a week, there are clear shortfalls in opening hours. Firstly, the dispensary closes for half an hour at lunchtime every day. During this time people in the town have no access to pharmaceutical services whatsoever. The problem is compounded by the long waiting times often faced by patients once the pharmacy opens (and provided as evidence with the Applicant s original application) so that if somebody arrives at the pharmacy at 1.00pm it may take much longer than half an hour to actually receive their medication The pharmacy closes at 6.30pm (though the Applicant notes the core hours are only until 6.00pm). Anybody currently requiring pharmaceutical services after this time faces a return journey of over 12 miles to Deal and back Finally, the pharmacy does not open at all on Sundays, not even as supplementary hours. In fact the Saturday hours are not core hours either so could be amended with 90 days notice. Therefore there is no guaranteed weekend provision of pharmaceutical services. Given the high number of tourists in the area, this is a 7 day/week town with many of the shops, restaurants and other attractions open throughout. The lack of any pharmacy provision on Sundays again results in residents and visitors travelling to Deal should they require services So, in terms of opening hours, it is again the Applicant s opinion that there is not reasonable choice provided at present because there are times when no service is provided at all If the PSRC shared the Applicant s view that the only pharmacy in Sandwich does not provide reasonable choice, then it must have had regard to the other pharmacies in the area when it decided that there was choice The nearest two pharmacies (Ash and Eastry) are both located more than 3 miles away. Both are located in the centre of small villages without dedicated parking. There is no reason for people, other than the residents of the villages themselves, to travel to these pharmacies as part of their day-to-day lives. Neither of these pharmacies open in the evenings, Saturday afternoons or Sundays Beyond Ash and Eastry, the next pharmacies are in Deal and, as referred to previously, travelling there from Sandwich requires a significant car journey. In the busy summer months busy roads make this a lengthy journey. Of the seven pharmacies in Deal, only one opens on Sundays so choice is still limited In the Applicant s opinion, given that residents and visitors alike can meet all of their needs in Sandwich it is not reasonable to make a special journey elsewhere simply to exercise their right of choice in respect of pharmaceutical

13 13 services, particularly when some of the same access difficulties will face them at these alternative pharmacies anyway. For these reasons the Applicant does not believe that the choice provided by pharmacies outside Sandwich should be given any significant weight The Applicant s comments above refer to the situation as it is today without even taking into account the implications of the new Waitrose and GP surgery development The location of the new site is at the southern edge of the town, away from the areas of traffic congestion and a short distance from the A256 Sandwich Bypass. It can be easily accessed by car without passing through the town centre. It is also located on the southern side of the railway line where there is a substantial existing population (around 2,000 residents) whose access to the town is limited by the presence of the railway line. There are two crossing points, each of which comprises level crossings with barrier controls so there is no means of crossing when trains are passing Feedback from public consultation carried out from Waitrose (see enclosed press release) suggests that when the new supermarket opens, it will be supported by a large proportion of the population of whom 82% are in favour. Given the availability of free and easily accessible parking this will be the destination of choice for those who do not want to contend with the town centre congestion Perhaps of even more importance will be the inclusion of the new Butchery Surgery. The new site is approximately 800m away from the existing pharmacy. Patients requiring pharmaceutical services following a visit from the surgery currently have a journey of less than 100m to travel. In the Applicant s opinion they will not find the additional distance required acceptable. Whilst 800m may be reasonable for a fit and healthy person to travel on foot, it is not for the elderly or people with mobility difficulties. Furthermore, patients who have travelled to the surgery by car will not find driving to the pharmacy straightforward as referred to previously As mentioned in the press release, there is extensive local support for the relocation of the surgery and inclusion of a new pharmacy. This is driven by the need to improve both access to pharmaceutical (and medical) services and the need to provide choice to drive up standards In the Applicant s opinion, therefore, taking all of these factors into account, it is clear that that there is not reasonable choice with regard to obtaining pharmaceutical services in this part of the HWB area. That being the case, NHS England should have approved the application on the grounds of choice alone Regulation 18(2)(b)(ii) Protected characteristics 3.40 As the Applicant has discussed previously, Sandwich is characterised by the elderly nature of its population.

14 The following table provides relevant demographic data for the Sandwich electoral ward (boundaries shown below) sourced from the 2011 census (ONS data). [map showing boundaries available to the Committee] Sandwich Ward England Average Mean (average) age People reporting their day to day activities as limited a lot People reporting their day to day activities as limited a little 9.6% 8.3% 11.6% 9.3% 3.42 Within this ward area alone, the population at the time of the 2011 census was 7,043. Of these people, 24.7% were aged over 65, a total of 1,738 people. By comparison the England average is 16.4%. Furthermore 270 people within the ward (3.8% of the population) were aged over 85 compared to the England average of 2.3% Given that the reliant population in this case is larger than the population of the electoral ward then the total number of older patients will be significantly larger than the numbers provided above. This patient group is growing rapidly (as people continue to live longer) so it is clear that the demands on pharmaceutical services will be put under even more pressure as time goes on In terms of the people whose activities are limited by illness or disability, in terms of absolute numbers this amounts to almost 1,500 people. Again these are people for whom pharmaceutical services are of critical importance The conclusions from this data are clear. The population of Sandwich Ward is relatively elderly and many of its residents, as might be expected, find their activities limited through some level of disability As both age and disability are protected characteristics it is particularly important to consider the extent to which these patient groups may currently have difficulty accessing pharmaceutical services As the Applicant has highlighted already, all residents and visitors have some difficulties in accessing existing pharmaceutical services but these issues are magnified for the elderly and less abled Access to the proposed site for all users will be straightforward in contrast to access to the existing pharmacy in Sandwich. This is particularly important when considering the needs of elderly and less able people who are patients of the Butchery surgery Regulation 18(2)(b)(iii) Innovation 3.50 The Applicant is aware it is difficult to provide evidence of innovation in a world where commissioning and specification of services is tightly controlled

15 15 by a range of public sector organisations. By its very nature, pharmacy is not traditionally an innovative profession However the Applicant would like to re-iterate the points made within the supporting information to their application under the heading services which describe how they have an almost unique track record in working at the forefront of pharmacy innovation. Services currently provided at the Applicant s nearby pharmacy in Broadstairs include the following: Chiropody & Foot Healthcare Treatment Medicines Use Reviews (MURs) Free Blood Pressure monitoring Free Diabetes testing Total and HDL Cholesterol testing Full Lifestyle Assessment Weight Management clinics Smoking Cessation Addict Services, including supervised consumption Travel Health Advice Palliative Care Drugs Young Persons Sexual Health Clinic Physiotherapy Anticoagulation clinic (including domiciliary visits) New medicines service MDS provision to care homes and individual patients Pharmacy Chlamydia screening Emergency hormonal contraception (EHC) service (both OTC and PGD) Repeat dispensing 3.52 As this list shows the Applicant is committed to delivering pharmaceutical services in an innovative way and has had significant success securing contracts for forward thinking services such as their anticoagulation clinic.

16 The Applicant s commitment to driving innovation in pharmacy is clear and has been recognised by their peers and throughout the industry. The Applicant has provided further evidence of this below and with additional attached documents: 3.54 Professional innovation 3.55 Improvement in cardiovascular risk factors in patients with diabetes The Applicant has attached a copy of an extract submitted to the British Hypertension Society describing a trial carried within their business demonstrating the role of the pharmacist in tackling these factors The Applicant has also attached a brief academic paper which provides more information on a pharmacy led study in this area This project is also described further here: %202012/MedicineDigest-winter2012.pdf 3.56 Health promotion (HLP model) The following link provides information on Healthy Living Pharmacy accreditation achieved by the Applicant s business and the recognised benefits of this initiative Blood pressure monitoring in pharmacies This link describes the model introduced in the Applicant s pharmacies to improve diagnosis and monitoring of hypertension: e_patients_who_slip_through_the_net 3.58 Development of an over the counter formulary This describes how the Applicant developed an evidence-based formulary for improved treatment of a range of minor ailments: 3.59 Awards _principles_to_a_practical_otc_formulary 3.60 The Applicant has been previously recognised through industry awards such as:

17 Pharmacy Business Awards: Alliance Healthcare awards: Contribution to the pharmacy profession 3.62 The Applicant is also a regular contributor to a number of professional publications and a commentator on matters of interest within the profession as can be seen on the following web pages: The Applicant believes, therefore, that they are uniquely qualified to provide a truly innovative and patient-centric pharmaceutical service for the residents of Sandwich Conclusion 3.65 This application will secure both improvements in, and better access to, pharmaceutical services for people resident in Sandwich and the surrounding areas as well as visitors, employees and patients of The Butchery Surgery The nearest pharmacy to the proposed location is difficult to access and does not offer reasonable choice The Applicant s proposed pharmacy will offer extended opening hours beyond those currently available in Sandwich. It is unique amongst the applications submitted in offering a true seven day service which will complement the opening hours of the new supermarket and therefore significantly improve access for people travelling from far and wide The pharmacy will also provide an extensive range of services which will further improve access for the local population and allow for true innovation in a location where it is much needed The Applicant respectfully requests, therefore, this appeal is upheld and the decision of NHS England is overturned. 4 Summary of Representations This is a summary of representations received on the appeal. A summary of those representations made to NHS England are only included insofar as they are relevant and add to those received on the appeal. 4.1 BOOTS UK LTD

18 Boots agree with the Kent and Medway Area Team's (AT) decision to reject the application submitted by Manor Pharmacy Group Boots would like to submit the following comments: Kent Pharmaceutical Needs Assessment (PNA) The new PNA for Kent, NHS Canterbury and Coastal Clinical Commissioning Group was published very recently (March 2015): NHS Canterbury and Coastal Clinical Commissioning Group: Page 13: Conclusions and recommendations 'The current provision of pharmaceutical services is good and provides the pharmaceutical needs of the population on the whole ' It is unclear what part of this application could not have been foreseen at the time of the drafting of the Pharmaceutical Needs Assessment (PNA). For the above reason, Boots believe that NHS England were correct to refuse the application The town of Sandwich Sandwich itself is an affluent, medieval, historical town and civil parish on the River Stour in the non-metropolitan district of Dover. There is currently one Boots Pharmacy in the centre of Sandwich which well caters for the population of Sandwich (total 4, Census). There are also two GP surgeries (The Market Place Surgery & The Butchery) both within a very short walk of the pharmacy. Boots has established itself in the town for a period of close to 20 years (October 1995) Sandwich is a unique market town that benefits from a number of high quality shops, for instance: a delicatessen, greengrocer, butcher, baker, sweet shop, card shop and newsagent as well as coffee shops, pharmacy and a recently refurbished and much improved supermarket. It is very possible that the opening of a new pharmacy could have a detrimental effect on the Boots pharmacy in the town centre. This could in turn have a negative effect on patients who currently enjoy the benefit of a centrally located pharmacy Relevant statistics for health in Sandwich from the Office for National Statistics are: % of residents have between very good health and fair health % of residents have between very good health and good health

19 Boots 17 Market Street Boots pharmacy is well situated within the town centre of Sandwich, it is a short walk from the two principal GP surgeries in the centre, 60 metres from The Butchery Surgery and 350 metres from The Market Place Surgery (according to Google Maps). There is a permanent pharmacist in place Deprivation Within the PNA, Sandwich is not mentioned as a deprived area in the Canterbury and Coastal locality. With areas of deprivation usually indicating areas of high health inequalities and therefore increased need for healthcare, Sandwich clearly does not fall into this category Services Boots pharmacy offers prescription collection and home delivery services from both local surgeries and they do receive electronic prescriptions from the Ash Surgery as well. Boots are EPS compliant and provide a free Medisure service for dispensing into compliance aids. Boots work with the Kent Community Health Trust Medicines support service to meet any additional needs or adjustments that patients may need to support taking their medication. The store will also be part of the DSP roll out which will increase capacity within the store The store also participates in the rotas that all pharmacies in Kent are part of to support Bank Holiday provision. There are no weekend rotas locally, the store has also trialled Sunday opening hours previously, but it was felt there was no need. However, Boots would once again be willing to take part in such a service if NHS England felt it necessary. Boots would be happy to work closely with the Kent & Medway Area Team of NHS England, Kent County Council's Public Health team and Kent Community Health Trust who commission the majority of the Public health services on behalf of Kent County Council to provide whatever additional service(s) may be deemed necessary in the local geography Opening hours As featured in the PNA (page 7), a review of all opening times was carried in May 2014 using data provided by NHS England which is available on NHS Choices. It concluded that; 'there is adequate provision of pharmaceutical services through pharmacies and dispensing surgeries for the majority of the day between 8am and 6.30pm. Services between 6am and 8am and between 6.30pm and 11pm are provided at strategic points across the area '.

20 Boots is happy to review the need for additional hours in the locality if the AT deems this necessary Boots' opening hours as follows: Core opening hours are as follows: Monday to Friday: 09:00-13:00; 14:00-18: The store's total opening hours are: Monday to Friday: 08:30-13:00; 14:00-18: Saturday: 09:00-13:00; 13:30-17:00 (pharmacy closed for lunch pm) * The hours above also show the times Boots is closed for lunch (just the pharmacy that is). However, as previously stated Boots is happy to look at its hours if there is an unmet need that needs to be delivered. This includes Sundays if required The staff Boots Pharmacist is accredited to provide Warfarin supplies on the East Kent PGO service and NRT on the East Kent PGO supply service. She is also accredited to provide witnessed administration to support patient taking medication for recovery from drug addiction. She is currently completing her accreditation to provide EHC on PGO and Chlamydia and has attended the recently run EHC update training as specified by Kent Community Health Trust, so she will be able to provide that service for the town as well Amongst the team Boots also have a Stop Smoking advisor who is now accredited and will provide a 1:1 advice service to support people who may need support to quit smoking. Boots also have 2 staff members who provide the Fresh Start Weight management service that is commissioned by Kent Community Health Trust to help people reduce weight Access - parking in Sandwich For patients wishing to currently access Boots pharmacy at Market Street, there is in fact on-street parking available on Market Street (CT13 9DA). Linear charging is in place, and the cost for 30 minutes is only fifty pence There is also on-street parking on New Street (CT13 9BB) where the same charges as Market Street apply. There are also 3 car parks in Sandwich, The Quay car park (CT13 9EN), The Guildhall car park, (CT13 9AP) and Gazen Salts car park (CT13 9EU). Additionally, there is customer car parking at The Co-Operative supermarket.

21 Boots have also included a document providing more detailed information on car parking in Sandwich Access The Boots pharmacy in Sandwich also provides a home delivery service to support patients who feel they are unable to visit the pharmacy to collect a prescription The introduction of electronic prescribing has also removed another barrier for patients as their prescriptions can therefore be sent to and provided by any pharmacy that has N3 connectivity and is EPSr2 compliant, The Boots pharmacy in Sandwich is able to provide this service The Boots Pharmacy complies with DDA requirements for access and has power assisted doors to support easier access by those in wheelchairs, with walking frames and parents with prams or pushchairs Pfizer U.K The local economy of Sandwich once benefited from significant investment by Pfizer U.K. However, in February 2011 Pfizer announced that the entire research and development facility at Sandwich would be closed within months, with a loss of roughly 2000 jobs. Due to this fact, it follows that there has been a marked decrease in the demand for pharmacy provision in the village of Sandwich Regulation Regulation 18 requires an applicant to explain why they believe that approving the application would confer significant benefits on people in the area that were not foreseen at the time of the Pharmaceutical Needs Assessment was published Choice As the NHS LA are aware, choice, as defined in the Regulations refers to that of 'reasonable' choice and applies to choice in the area of the Health and Wellbeing Board. It is not confined to a particular village, town or neighbourhood. Boots submit that the appellant has not provided any evidence that there is a lack of reasonable choice with regard to obtaining pharmaceutical services in the Health & Wellbeing Board Protected characteristics The applicant has not provided any evidence of patients with protected characteristics currently experiencing difficulty accessing pharmaceutical services that meet their specific needs in Sandwich.

22 Innovative services The applicant has not proposed any innovative approaches in the delivery of pharmaceutical services as intended within The National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations Amongst listing the awards the applicant has won, as well as the publications the business has contributed to, the applicant states; 'I am uniquely qualified to provide a truly innovative and patient-centric pharmaceutical service for the residents of Sandwich' As a principle, no pharmacy should be seen by the public to create an invidious distinction between pharmacists or pharmacies. Patients, the public and the government have an expectation of a minimum standard of pharmacy as a profession Conclusion In conclusion, Boots believe that the applicant has failed to provide sufficient evidence to support their application for unforeseen benefits in Sandwich. Boots is mindful of chapter 8 of the guidance to the regulations and in particular paragraph 14 that states: The applicant must explain in the application why they believe that approving it would confer significant benefits on people in the area of the PCT that were not foreseen when the PCT published its PNA (regulation 18(2)(b) and paragraph 7(1)(b) of Schedule 2). It is not sufficient to offer to provide a service or services for which there is no basis in the PNA. Unforeseen benefits must be fully evidenced.' Boots respectfully urge the NHS Litigation Authority to dismiss the appeal accordingly Please be aware that Boots may wish to make further representations at a later stage and attend any oral hearing that may be held. Boots trusts its representations will be of assistance to the Pharmacy Appeals Committee when making their determination. 4.2 NHS ENGLAND Regulation The PSRC did not believe that Regulation 31 was relevant to the consideration of this application Regulation 18(2)(a) The Committee considered whether the granting of these applications would cause significant detriment to the proper planning, or the