APPROVED

NHS GRAMPIAN

Minute of Meeting of GRAMPIAN NHS BOARD held in Open Session

on Friday 16 January 2015 at 1pm

in Committee Room 5, Woodhill House, Westburn Road, Aberdeen

Present

/ Professor Stephen Logan / Chairman
/ Mr David Anderson / Non-Executive Board Member
/ Mrs Rhona Atkinson / Non-Executive Board Member
/ Mr Raymond Bisset / Non-Executive Board Member
Cllr Stewart Cree / Non-Executive Board Member
Dr Nick Fluck / Medical Director
Mr Alan Gray / Director of Finance
Professor Mike Greaves / Non-Executive Board Member
Mrs Christine Lester / Non-Executive Board Member
Mr Terry Mackie / Non-Executive Board Member
Dr Helen Moffat / Chair, Area Clinical Forum
Mr Jonathan Passmore / Non-Executive Board Member
Cllr Anne Robertson / Non-Executive Board Member
Mr Eric Sinclair / Non-Executive Board Member
Mrs Elinor Smith / Director of Nursing and Quality
Mr Malcolm Wright / Interim Chief Executive
By / Mrs Laura Gray / Director of Corporate Communications/Board Secretary
invitation / Dr Annie Ingram / Director of Workforce
Mr Andrew Jackson / Legal Advisor
Mr David Pfleger / Director of Pharmacy and Medicines Management
Mr Graeme Smith / Director of Modernisation
Dr Pauline Strachan / Deputy Chief Executive
Mrs Susan Webb / Acting Director of Public Health
Attending / Miss Lesley Hall / Assistant Board Secretary
Mrs Glenys Wells / PA, Board Secretariat
Item / Subject /
1 / Welcome/Introductions
Professor Stephen Logan began the meeting by introducing himself as the new chairman of NHS Grampian. He welcomed everyone to the meeting, particularly the two new Non-Executive Board members, Mrs Rhona Atkinson and Mr Eric Sinclair.
2 / Apologies
Mrs Sharon Duncan, Councillor Barney Crockett and Dr Lynda Lynch.
3 / Review of continued dispensing from the Haddo Medical Group
The Board had before it a paper prepared by Dr Nick Fluck, Medical Director, for consideration.
Mr Bisset advised that he was Chair of the Aberdeenshire Community Health Partnership (CHP) which had considered this matter. To avoid any conflict of interest, and as he wished to carry out his role as a Non-Executive member of the Grampian NHS Board, he had not taken part in the CHP discussion and had left the room when the item had been discussed.
The Chairman advised of the process to be followed at the meeting and advised of two preliminary procedural matters.
Firstly, the note of the Review Group meeting on 10 December 2014 omitted to include Mr Brian McDougall’s name and designation in the list of attendees for which he apologised. (It was subsequently noted that Mr Iain Ramsay’s name and designation had also been omitted). The final note of the meeting would be amended accordingly.
Secondly, the Area Pharmaceutical Committee’s submission had been received outwith the time-limit as the committee chair had been absent from work on sick leave and the committee had not met until 13 January 2015. The Board agreed to accept the late submission, following which members were given the opportunity to read it.
Mr Pfleger explained the background to the item being presented to the Board, with reference to the key milestones listed in appendix A to the paper. The Board noted that the complex process had culminated in a Judicial Review of the Grampian NHS Board’s decision to allow continued dispensing of medicines by the Haddo Medical Group (HMG) for patients living in all areas except that covered by the Tarves neighbourhood. Following Lord Doherty’s decision at Judicial Review that NHS Grampian’s decision was unlawful, NHS Grampian began an urgent review of the continued dispensing for those patients who continued to have their medicines dispensed by HMG. This included public consultation and awareness-raising with local communities, as well as NHS Grampian sending a questionnaire to all patients over 16 currently eligible for dispensing from HMG. The Review Group had met on 10 December 2014 and its recommendations were appended to the paper presented to the Board.
Dr Fluck explained that he had chaired the Review Group. The other members were two Non-Executives – Cllr Stewart Cree and Dr Helen Moffat. He explained that the review had focused on two areas highlighted by Lord Doherty:
a)  The decision was unlawful in not providing Tarves Pharmacy with the opportunity to represent itself at the review Group and the NHS Board meeting. This was in contrast to the Community Council which was permitted to attend and present to both. This was deemed unfair and unlawful.
b)  The decision was unlawful as it permitted continued dispensing for all patients living outside the Tarves neighbourhood despite the Review Group finding that only a proportion of individuals in that population had a serious difficulty of access to a pharmacy.
The Review Group did not consider additional consequences of its decision or mitigation of any impact of its decision. The focus had been on Paragraph 44 of the NHS (General Medical Services) Regulations 2004. The Review Group had considered documentation and written submissions as well as presentations from the interested parties. Advisors had been available to advise the group on technical matters.
Dr Fluck advised that the interested parties had presented arguments well and had highlighted difficulties for patients. Following the group’s deliberations, it had made its decision as stated in its report i.e. that some patients on some occasions would have a serious difficulty in obtaining medication in a timely manner after a doctor’s appointment that led to an acute prescription.
The covering paper set out three recommendations to be dealt with separately. The impact of the Board’s decision was recognised and NHS Grampian had a responsibility to mitigate this. It was pointed out that national guidance was limited and inconsistent regarding what constituted “serious difficulty”.
The following interested parties, that had provided written submissions, were given the opportunity to make a verbal statement to the Board in relation to the recommendation of the Review Group and its implementation.
·  Mrs Kathy Kennedy, Methlick Community Council
·  Mr Brian McDougall, Udny Community Council
·  Mr David Hekelaar, Tarves Community Council
·  Dr Fiona Munro, Haddo Medical Group
·  Mrs Lindsay Craig, Tarves Pharmacy
·  Dr Adam Coldwells, Aberdeenshire CHP
·  Mrs Ann Smith, Area Pharmaceutical Committee
Board members were given the opportunity to ask questions at the end of each statement. In response to queries, Mrs Craig responded that there was no restriction on who could receive a delivery and that deliveries were free of charge. Dr Coldwells advised that a needs assessment would be based on the whole population of the area. He stressed the importance of strategic planning for the future and that the integration of health and social care would be integral to this.
After all the parties had presented, the Board had an opportunity for discussion. Mr Pfleger confirmed that it was necessary for the Board to correct an unlawful decision and Board members agreed. The Board had to be clear that the contextual impact of its decision was not relevant in terms of the regulations, but was important for how NHS Grampian provided services to its population.
The Chair asked for clarification that it was currently unlawful for NHS Grampian to require HMG to dispense. Dr Fluck clarified that the current unrestricted dispensing was unlawful and therefore had to be restricted to those who “will have serious difficulty ...”
Professor Greaves had been persuaded by the information provided and agreed that there was a cohort of patients who will have a serious difficulty and that the delivery service did not completely mitigate this. Mr Passmore agreed it was important not to set a precedent. Mr Anderson was concerned at the difficult circumstances made more difficult by political pressure. He acknowledged the difficulties for the practice of enforcing the recommendations.
It was noted that there were other pharmacies in the area providing delivery services including Ellon, Inverurie and Oldmeldrum. There was no contractual basis for a delivery service, but these services continued by custom and practice. It was noted that the services provided by pharmacies were governed by professional standards.
The Chairman acknowledged the enormously complex situation. He reminded the Board of the two areas in which Lord Doherty had found against NHS Grampian. The first of these, relating to the procedural matter of allowing the pharmacy to be represented, had had been rectified by the current review panel process. The second of these was that the decision to allow dispensing to a whole set of patients was unlawful. Therefore it was logical that it would be lawful to dispense to a subset that “will have serious difficulty”.
Normally a practice was given a 12 month notice period to stop or change dispensing. Given the circumstances in this case, Mr Pfleger recommended a 3 month period. This would create practical issues for the practice but if it was any longer there was the threat of a further legal challenge.
It was suggested that there be a shortened notice period and steps taken to mitigate the impact on the practice and to ensure fairness to the community.
Board members expressed the view that there was a moral duty to deliver what services were best for patients. Queries were raised about whether the practice could be compensated in some way to ensure it continued to provide services to patients.
Dr Strachan suggested that the two issues be separated. She agreed there was an absolute need to make the Board’s decision legal and the recommendation of the Review Group allowed the Board to do that. The issue about provision of general medical services from HMG would require discussion with the practice. GPs were independent contractors and independent of the Board, but as the practice had cooperated with NHS Grampian in the past, she was confident it would continue to do so.
The Chief Executive pointed out that this had been a difficult and challenging discussion and the Board had heard strongly held views from the communities. He stressed the point that the Board had to obey the law and required to correct a decision that was unlawful. He also acknowledged that NHS Grampian needed to assess and mitigate the impact on the practice and its patient population.
At the conclusion of the discussion the Board agreed with the recommendations in the paper:
1.  That the Grampian NHS Board, under the authority granted to it under the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004 Paragraph 44 of Part 3:
a)  Continues its authority for Haddo Medical Group to dispense to patients who have a serious difficulty in obtaining their medication from a pharmacist.
b)  That this authority should be limited to dispensing to patients, living outside the neighbourhood of Tarves, who ‘will have serious difficulty in obtaining from a pharmacist any drugs required for that person's treatment' by virtue of both the need to obtain medication following the issuing of an acute prescription and that on that day they do not have access to a car to travel to a pharmacy.
2.  That prior to implementing this decision NHS Grampian should:
a)  Undertake an impact assessment of implementing the recommended limitation on dispensing, by the Haddo Medical Group, to the delivery of General Medical Services to the area and any consequences this limitation might have on the duties of NHS Grampian in the discharge of its responsibilities to the local population.
b)  Work with local stakeholders to agree a timeline for the implementation of this limitation on dispensing as soon as reasonably practicable, following the impact assessment, in the interests of all affected parties.
3.  That NHS Grampian conducts a review of general practice dispensing across the region to formulate clear objective criteria around interpretation of the General Medical Services regulations to ensure patients have access to the most appropriate services to meet their clinical needs.
In terms of recommendation 2, the Deputy Chief Executive and Chief Officer for Aberdeenshire CHP were asked to take urgent steps to address the impact of the Board’s decision and to take steps to mitigate any adverse effects. An update on progress was requested for the Board in two months.
The Chairman acknowledged that it had been a difficult debate carried out with diligence to reach the final decision.
Signed...... Date ......
Chairman

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