PHB 12

Bil Iechyd y Cyhoedd (Cymru)

Public Health (Wales) Bill

Ymateb gan: Fferylliaeth Gymunedol Cymru

Response from: Community Pharmacy Wales

The Community Pharmacy Wales response to The Health, Social Care and Sport Committee inquiry into

The General Principles of the Public Health (Wales) Bill and the Committee’s Terms of Reference

Date: December 2016

Contact Details

Russell Goodway

Chief Executive

Community Pharmacy Wales

3^rd Floor, Caspian Point 2

Caspian Way

CARDIFF, CF10 4DQ

Tel: XXXXXXXXXXXXXXX

E-Mail XXXXXXXXXXXXXXXXXXXXXX

Part 1: Introduction

Community Pharmacy Wales (CPW) represents community pharmacy on NHS matters and seeks to ensure that the best possible services, provided by pharmacy contractors in Wales, are available through NHS Wales. It is the body recognised by the Welsh Assembly Government in accordance with Sections 83 and 85 National Health Service (Wales) Act 2006 as ‘representative of persons providing pharmaceutical services’.

CPW represents all 719 community pharmacy contractors in Wales. These include all the major pharmacy multiples as well as independent businesses. Contractors are located in high streets, town centres and villages across Wales as well as in the major metropolitan centres and edge of town retail parks.

In its response to the proposals contained in the original Public Health (Wales) Bill, CPW welcomed and fully supported the intentions of the Bill. Both the original and the revised Bill seek to ‘adopt a preventative approach across its provisions and is therefore consistent with the principles of prudent health care. It does this by seeking to intervene at points with significant potential for long-term benefits, both for the health of individuals and in avoiding the longer term burdens caused by avoidable ill health. In doing so the Bill also focuses on protecting the future health and well-being of children and young people in Wales’. This approach and these principles lie at the very heart of the delivery of community pharmacy services and CPW is therefore strongly supportive of the revised Bill and its aims.

Community Pharmacy Wales (CPW) welcomes the Welsh Government's recognition of the important role that well informed and proactive public health interventions can have in the health outcome of patients and in the effectiveness of health service delivery. CPW particularly welcomes the Welsh Government's recognition of the central role that community pharmacy plays in this and its identification as a "community asset". However, like much of the potential of community pharmacy the public health role is still underdeveloped, despite some notable advances in recent years.

Part 2: The principles contained within the Public Health (Wales) Bill

As the Bill is a broad bill, it covers and covers a number of areas which are outside of the responsibilities and expertise of community pharmacy, CPW has limited its observations to those areas that fall within its remit.

Changes to the arrangement for determining pharmacy applications

“Change the arrangement for determining applications for entry onto the pharmaceutical list of health boards (LHBs) to a system based on the pharmaceutical needs of local communities”

Community Pharmacy Wales strongly supports the proposal to introduce PNAs in Wales. The inclusion of the promotion of healthy lifestyles within essential services of the pharmacy contract has already provided a platform to extend the role of community pharmacies in health promotion activity.

The development and implementation of Pharmaceutical Needs Assessment (PNA) provides the potential to build on this and take it further, placing community pharmacies as key enablers of health improvement. The amendment of the control of entry test will, if fairly and appropriately used, contribute to ensuring that these services are available equitably across Wales. This approach could potentially contribute to a reduction in persistent health inequalities.

PNAs are generally described in outline within the provisions of the Bill. Provisions about the carrying out of assessments including their contents, the extent to which they should take account of future needs/other matters, consultation and procedural requirements are all to be set out in future regulations. Provisions about timescales, circumstances in which the Health Board should review/revise its assessment and the way in which assessment should be consulted upon and published will also be set out in regulations.

It is clear that these regulations will be critical in realising the potential of PNAs as a dynamic tool for driving health improvement. In addition, changes to regulations affecting control of entry have the potential to have a profound impact on existing pharmacy businesses and the livelihood of the pharmacy owners and there is a responsibility on the health boards to ensure that PNAs are drawn up with a degree of rigour and with the necessary investment in resources. CPW would ask that the Committee ensure that the Bill clearly lays out national standards and guidelines in relation to the creation and publication of PNAs. If the regulations are not well developed there is a risk of significant variation in development and implementation of PNAs and, in extreme circumstances, the risk of legal challenge. As PNAs were introduced in England a number of years ago, CPW would expect that discussions have taken place to ensure that any lessons learned from their introduction in England is incorporated in the guidance for Wales.

Community Pharmacy Wales believes that consideration needs to be given to the following issues in taking forward the PNA provision within the Bill:

• Ensuring that existing contractors are provided with the opportunity to meet any identified gaps in provision before the market is opened to potential new entrants.

• Only the provision of services, for which the health board has commissioning arrangements in place, should be identified as inadequate provision.

• Formally changing the definition of pharmaceutical services, which currently relates only to dispensing services, to reflect the wider role envisaged in the PNA provision

• There should be a national approach to developing PNAs including a national template, national review process and national criteria for new pharmacy recommendation and for breach notices. This will avoid duplication of effort and variation and inconsistency between Health Boards and will ensure a ‘Once for Wales’ approach.

• Community Pharmacy Wales, together with other key stakeholders, should be involved in drafting the regulations and all stages of the PNA writing and review process

• The development of PNAs should be linked to the discussions on the development of the pharmacy contract

• The national development of PNAs should draw on learning from experiences in England where they have been in place since 2009

• PNAs should be integrated into the general needs assessment, service planning and commissioning processes of Health Boards including Health and Well Being and Integrated Medium Term Plans avoiding a ‘silo’ approach.

• PNAs should cross organisational boundaries as patients do and not be geographically limited

Community Pharmacy Wales is willing to take a key role in the development of PNAs to develop and enhance the role of community pharmacies in improving public health.

Provide for the creation of a national register of retailers of tobacco and nicotine products.

The Bill refers in Part 2 to ‘tobacco and nicotine products’ CPW would draw the attention of the Committee to the fact that Nicotine Replacement Therapy (NRT) is the most common support provided to help people quit smoking. NRT products themselves contain nicotine and CPW would not want community pharmacy stop smoking services to be inadvertently caught up in the legislative change. In addition community pharmacies dispense prescriptions for NRT products and many members of the public will purchase NRT products over the counter in community pharmacies as part of their own quit attempt and, as NHS Wales has clearly stated its desire to increase self care, it would be counter productive to put in place any barriers to self care.

Whilst fully supportive of the intent of the provision CPW would ask the Committee to ensure that there is an exemption, from all of the requirements of the legislation, for pharmacies providing medically licensed nicotine replacement therapy, against a prescription, as part of a stop smoking service or in response to a request to purchase an over the counter medicine.

Part 2(b) similarly makes provision for ‘there to be a register of tobacco and nicotine products in Wales’. The exemption referred to above would ensure that community pharmacies are exempt from these arrangements.

Part 2 (d) makes it an offence to “hand over tobacco, cigarette papers or a nicotine product to someone aged under 18”. As many NHS Wales commissioned stop smoking services allow for the provision of NRT to people under the age of 18, deemed to be competent to participate in the service, it is essential that the above exemption is applied otherwise a number of effective stop smoking services would inadvertently become illegal.

In addition many NRT products used as a stop smoking aid are licenced for supply to people aged 12 and over and without the above exemption community pharmacies would not be able to provide prescribed stop smoking aids, or those purchased for a self quit attempt, to those judged by a healthcare professional as competent to receive the product, unless accompanied by an adult. Without the above exemption, the Welsh Government could, as an unintended consequence, put barriers in place to young people seeking the support of their GP or pharmacist to quit smoking.

One of the NRT products used in community pharmacy stop smoking services provides for the delivery of replacement nicotine through the use of an inhalator. Particular care is needed in the framing of the Bill to ensure that this product is not inadvertently removed from a pharmacy’s stop smoking armoury.

The bill similarly makes provision for powers of entry and inspection for premises selling cigarettes and nicotine products and as community pharmacies are already highly regulated and health boards, community health councils and the industry regulator already have powers of entry and inspection it is essential that community pharmacy is exempt from the arrangements. That said: CPW would not expect there to be an exemption from these requirements for pharmacies that choose to sell e-cigarettes.

Health Impact Assessments

In Part 5, the Bill contains a ‘requirement to carry out Health Impact Assessments’ by public bodies to assess the likely effect of proposed changes on the physical and mental health of the people of Wales.

CPW view this as a positive development and would, as a result, expect to see a requirement placed on Local Health Boards to undertake a Health Impact Assessment before taking a decision to decommission a community pharmacy service. This would put appropriate safeguards in place and ensure that decisions of this nature are judged against population requirements and not other drivers such as a desire to make financial savings.

Unintended consequences arising from the Bill

The Health, Social care and Sport Committee has asked to be alerted to “any unintended consequences arising from the Bill”.

CPW has raised above the risk that tighter controls applied to the supply of nicotine products has the potential to impact on the supply of NRT products against a prescription, as part of a community pharmacy stop smoking service, or as part of a persons self quit attempt. In addition the Bill could put barriers in place to younger people attempting to quit smoking and, if not handled correctly, create unnecessary, additional regulatory burden on the community pharmacy network taking them away from patient care.

The only other unintended consequence of which CPW is alert to is a potential to impact on the goodwill values of community pharmacies. The goodwill attached to a community pharmacy is based on a number of factors amongst which are the nature of the market and the competition within it. Any change to control of entry arrangements has the potential to impact on both of these factors and, depending on the findings of the published Pharmaceutical Needs Assessment, may do so in a negative manner.

Part 3: Conclusion

CPW is fully supportive of the aims of the Public Health (Wales) Bill and in particular the aim of supporting the community pharmacy network to better meet the defined needs of local populations. Community pharmacies across Wales are currently on the front line in tobacco control and deliver many thousands of stop smoking interventions. CPW is asking the Committee to ensure that the network is able to carry on with this excellent work and is therefore exempted from the requirements of this part of the Bill.

CPW agree that the content of this response can be made public.

CPW welcomes communication in either English or Welsh.

For acknowledgement and further Contact: