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    Last year I told you about a group of 7,000 health professionals who had spent 7 years fighting for their trade union to be recognised by their employer. That campaign has now lasted 8 years. See: https://www.sochealth.co.uk/2018/05/05/solidarity-with-community-pharmacists/

    The Boots pharmacists were the first workers in any sector to challenge an employer through the ballot process described in that earlier article (above).  The law requires not just a majority, but that 40% of those eligible to vote, known as the “bargaining unit”, must vote “Yes” to make a difference.  The result was 87% of those who voted (2,826 pharmacists) voted Yes and that constituted 41% of the bargaining unit in favour.  This passed all the legal tests and the blocking agreement with the “sweetheart” union that the company was using to keep independent trade unions out, was ended by order of the Central Arbitration Committee.

    To emphasise what an achievement that is, if you measure the BREXIT referendum in similar percentages, of those eligible to vote it was just 37% vs 35%, so getting over 40% of eligible voters to support anything is no small achievement. Despite the clear result, the employer has continued to resist pharmacists’ efforts to secure an independent voice at work in the largest community pharmacy multiple chain.  However, in February 2019 the 7,000 pharmacists can vote again in a further postal ballot and this time it will force the employer to recognise the PDA Union

    One of the big issues for pharmacists is the company’s approach to performance management and the union have been hearing from pharmacists about what it means to them.  These quotes from pharmacists illustrate what the PDA Union are trying to fix so that these health professionals can get on with caring for patients.

    “In regards to its pay structure and market based pay it should be ashamed. It should be ashamed for its performance review where no person I have spoken to has any idea what it means to be above performing and where the pharmacy advisors, the people on the front lines get no bonus at all unless they are above performing.

    Nobody knows what exactly they need to do to be “above performing”. Even if you hit all your targets and are green on the scorecard despite those targets being an increase you are performing.”

     

    “I worked under this regime and it is a terrible way to work. The constant threat of a ‘non-performing’ rating is so demotivating and demoralising and it sometimes felt like a personality contest. I challenged it many times (probably another reason I would never win a corporate personality contest) and was told that even if all targets were met/exceeded you could still be classed as non performing so what’s the point!”

    Ballot papers will be mailed to pharmacists on Monday 18 February and completed ballots must be returned by noon on Monday 11 March in order to be counted.

    Boots directly employs well over 10% of all pharmacists in the country and has many more working occasionally as locums, so this is a significant story for pharmacy, but sadly under reported by the media.  Anyone interested in supporting the PDA Union and their members can help by spreading the word about this historic trade union campaign.

    The PDA Union was established in 2008, it is the only independent trade union in the UK which is exclusively for pharmacists.  It received a certificate of independence in 2010.  PDA Union is a member of Unions 21 and affiliated to the Employed Community Pharmacists in Europe (EPhEU) organisation and a member of Health Campaigns Together.  You can follow the PDA on Twitter, Facebook, Instagram and LinkedIN

    Written by Paul Day, National Officer at PDA Union.

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    Did you know there are a group of 7,000 UK health professionals whose employer has spent 7 years, and who knows how much money, preventing them from gaining an independent voice at work?

    What if I told you that part of this situation involves an entity, which is supposed to represent workers, that has signed an agreement with management committing to only “collective bargain” resources for their own officials and committing not to collective bargain for the employment terms of their members?

    This is what happened at Boots when the company signed an agreement with the “Boots Pharmacists Association” (BPA) in 2012 and in law this is enough to block an independent trade union, the PDA Union, from following the statutory process for recognition at that employer.

    The BPA is on the certification officer’s list of trade unions, but it is not independent. BPA was refused a certificate of independence in 2013. Part of the certification officer’s decision said: “looking at the picture as a whole that there emerges, in my judgement, a clear image of a union that has over the years been drawn into a situation in which it is indeed liable to interference by Boots… tending towards domination or control.”.

    Boots is the largest and most well-known community pharmacy business in the UK. The multi-billion pound global enterprise is a vertically integrated business profiting from both wholesale and retail sales of medicines, with much of that coming from the taxpayer via the NHS. The company has tried “everything” to block their employed pharmacists from getting independent representation and that includes the blocking agreement signed in secret with BPA at a time the company was simultaneously talking to PDA Union about statutory recognition.

    The good news is that the pharmacists have never given up and last summer six pharmacists, supported by PDA Union, applied to the Central Arbitration Committee to have the Boots-BPA agreement ended. Over 1,000 more employees pledged online to support the application, and after a further legal hearing at which the company and BPA’s joint attempt to give votes to senior managers (if they are a registered pharmacist) was overcome, a ballot is about to be held of almost 7,000 pharmacists working in Boots stores to end the blocking agreement.

    The law under which this ballot is happening has never been used before in any sector and the union must achieve 40% of those eligible to vote, to vote in support, hence their #2780pharmacists campaign hashtag.

    Ballot papers go out from 10 May and must be returned by 23 May in order to be counted. Anyone interested in supporting the PDA Union and their members can help by spreading the word about this historic trade union campaign.

    • Paul Day, National Officer, PDA Union @the_pda_union
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    Advanced paramedics in England will be able to prescribe medicines to people who do not need hospital treatment, under new laws starting on Sunday.

     Who will be able to prescribe?

    Advanced Paramedics  – those undertaking or having completed a Master’s-level (Level 7) qualification – will be allowed to complete a prescribing module, if their employed role has a need for it (i.e. you must be employed in a prescribing role, e.g. in a GP surgery. An AP cannot complete it if employed in a standard frontline paramedic role where prescribing is not a required qualification).

    How does this fit with other professions?

    Many other health professions can already prescribe. Nurses led the way, followed by various others including radiographers and chiropodists.

    Will this mean frontline paramedics will prescribe?

    No. To register, frontline paramedics have only completed a Bachelor’s-level qualification (Level 6) (from 2021), a Foundation level qualification (currently) or an in-work IHCD qualification (in the past), and therefore will not be able to apply for the prescribing module.

    Why are paramedics being given the ability to prescribe?

    Paramedics don’t just work in ambulances. We also work in GP surgeries, A&Es, walk-in centres, and Intensive Care Units across the country. Many of these roles are limited because the Advanced Paramedic, often employed alongside Advanced Nurses or other Advanded Allied Health Professionals, cannot prescribe, unlike their nurse & AHP counterparts. The change to the law will allow these to work equally to other professions, and will expand the number of range of jobs Paramedics can do (e.g. why employ an Advanced Paramedic who can’t prescribe, when you can employ an Advanced Nurse who can?).

    Will there be any prescribing in the Ambulance setting?

    Paramedic Prescribing is up to each Ambulance Service Trust to implement. There is certainly scope for benefiting the patient & the system if Advanced Paramedics are able to support frontline crews with prescribing skills. There are many cases where patients are taken to hospital or referred to the out-of-hours GP for a simple prescription that could, now, be handled by the ambulance service.

    Is prescribing just for non-emergency cases?

    No. Paramedic Prescribing will also widen the range of drugs paramedics are able to administer in an emergency when supported by an Advanced Paramedic. This too will be up to each Ambulance Service Trust to implement.

    Won’t people just call for an ambulance for a prescription because its quicker than waiting to see a GP?

    This question assumes that ambulances currently only go to emergency cases. This isn’t true, and we already attend many non-emergency cases that could/should be dealt with outside of the ambulance service. This has become the case through a combination of factors discussed in another article. Many of these patients, now they have entered an ambulance system ill-equipped and ill-trained to deal with their non-emergency health condition, are fed into the out of hours GP or hospital system.

    Giving the ambulance service the ability to prescribe will not reduce the amount of non-emergency cases we attend, but it will reduce the onward burden of these cases to other health systems.

    Furthermore, sometimes patients have multiple needs, some of which are urgent and some non-urgent, which may all contribute to an ambulance call-out. For example, a patient may have fallen and is unable to get up – a paramedic’s bread & butter – but the patient may also have an underlying chest infection or unmanaged chronic pain, which could have caused the fall.

    Say you’re wrong. What happens if calls for non-urgent cases do increase?

    The underlying issue here is that the Ambulance Services are already stretched between trying to provide quality care to both emergency and non-emergency groups. The concern highlighted in this question is that this tension may increase further if the patients begin to use the ambulance service in order to obtain a prescription quicker.

    The solution is not to stop ambulance services from prescribing in order to manage the tension, but to look at the systems that bring about the tension in the first place.

    Here I wrote how current ambulance services might overhaul the system by providing only emergency care, while another group of paramedics, either still employed by the ambulance service but with exclusive resources, or employed by new non-emergency ambulance services or by GP surgeries themselves, could handle non-emergency care.

    Paramedic Prescribing increases the ambulance services ability to provide 24 hour care in the community, independent of other services, across a whole range of acuities.

    This provides a potential solution to the increasing difficulty found by General Practitioners to be able to afford to conduct home visits and to provide out of hours care. Ambulance Services have held GP visits & OOH GP contracts in the past, and have delivered well. As long as we ensure that this doesn’t impact the emergency care delivery, ambulance services could reshape the landscape of care in the community.

    Where can I find out more?

    The College of Paramedics has led the campaign for paramedic prescribing, and has a lot of good information and documents on their website.

     

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    In 1948 the leaflet distributed to every household about the forthcoming NHS said “Your doctor will give you a prescription for any medicines and drugs you need.”

    In 2018 NHS England is conducting a consultation which proposes to restrict prescriptions of over-the-counter medicines for 33 minor, short-term health concerns. About £569 million is spent each year on these items and these proposals could save about £136 million.  That sounds a lot, but as a proportion of the £124.7 billion English NHS budget it isn’t a lot.

    For most of us that is not a big problem.  Most of this stuff isn’t very expensive.    The recommended Chemists’ Own Head Lice Spray is £5.90, and that is one of the more expensive items involved.  We mostly don’t take headlice as seriously as we used to either.  But do we expect poor people to leave headlice untreated?  That seems a really good way of stigmatising them.  That is why we used to employ nurses specially to deal with headlice.

    Nit nurses

    But single people under 25  on Universal Credit are expected to live on £251.77 a month.  Once you reach 25 it goes up to the princely sum of £317.82  a month with £231.67  a month for a child. Some of the people to whom this applies are likely to have other problems. For example young pregnant women, who barely have enough money to eat properly.   It doesn’t seem sensible to put them in a position of choosing between food and medication.

    There are also problems for people in residential and nursing homes.  Many of them will have difficulty in caring for themselves, won’t be able to buy items over any counter, and have no disposable income at all.   The consultation document says that all care homes should be encouraged to adopt a Homely Remedies Policy, which would enable them to administer these low risk treatments.  It also appears to imply that the home should pay for them.  Given the financial situation of many care homes – and the medical condition of many of their residents, who are very likely to be suffering from minor pain, constipation, diarrhoea and the like – this seems unreasonable.

    The system of free prescriptions in England is a complete mess.  There is a list of illnesses which qualify you for free prescriptions. These are conditions for which there was life saving medication in 1968.   Cancer patients were added by Gordon Brown in 2009.   Everyone over 60 gets free prescription but younger people more than a couple of pounds over the means test limit (£57.90 for people under 25) have to pay £8.60 per item unless they can find £104 for a season ticket.

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    The Government’s decision to push ahead with the huge funding cut for community pharmacies shows no understanding of the contribution that community pharmacies make to patients, communities and to the NHS as a whole. I was the proud owner of a community pharmacy in Burnley form 1986-2010 and I know just how vital these community assets are.

    That’s why Labour is announcing today that we are calling a vote in Parliament next week on the cuts to community pharmacies and urging Tory MPs to vote with us to save their local pharmacies.

    How often have we heard in recent times the NHS slogan “The Right Care, at the Right Time, in the Right place?” For many healthcare and general well being needs, the local pharmacy is the right place to provide treatments, advice and important signposting. Pharmacists have five years of intensive training and really are the experts on all issues related to medication. They keep up to date by means of a comprehensive programme of continuing professional development and standards are rigorously monitored by the General Pharmaceutical Council. As an absolute minimum all pharmacy staff are trained to give advice on the safe use and sale of medicines and it is not unusual for staff to have completed training to support the pharmacist with everything from dispensing to patient counselling.

    It really is time that the Government recognised that the contribution of community pharmacies goes way beyond the dispensing of prescriptions and the sale of paracetamols. On the contrary the typical community pharmacy provides a whole range of services to assist with the promotion of health and well being in the wider community. All community pharmacies have consulting areas where patients can speak privately also providing a perfect space for the provision of a variety of important services which typically include smoking cessation programmes, dietary advice, Emergency Hormonal Contraception (the morning after pill) and the administration of flu vaccines.

    Far from being a costly drain on NHS resources, community pharmacy is well placed to actually save vital funds in a variety of ways. MURs (medication use reviews) are a good example of this. MURs are offered by most community pharmacies and are particularly helpful for patients who take a lot of medication on a regular basis, ensuring that the patient has the right combination of items, that they understand what their medication is for and when and how it should be taken.

    Such reviews often identify medicines that are routinely ordered but no longer needed and thus wasteful stockpiling of such items can be avoided. In many parts of the country minor ailment schemes operated by community pharmacies provide a useful and cost effective service whereby pharmacists can issue treatments for a whole range of minor ailments. Not only is such a service convenient for patients, removing the necessity for a GP appointment it is an immense help to the GP practice freeing up time for doctors to see patients with more serious conditions. It is of course hard to quantify the savings that this generates in terms of the cost of GPs time but they surely go beyond significant and have the added benefit of taking pressure from busy GPs facing unprecedented levels of demand. It is even harder to evaluate the financial benefit and wider social impact of the extensive support that community pharmacies provide for patients with substance abuse issues including methadone programmes and needle exchange schemes.

    While the debate has rolled on in recent months there has been much discussion about the value of pharmacies in isolated rural communities. Undoubtedly pharmacies are vital in such communities, but I would just like to take a moment to consider the value of community pharmacies to urban populations and particularly areas of high deprivation. In community settings where low pay, poor housing, child poverty, substance abuse and unhealthy lifestyles combine to affect the life chances and life expectancy of too many, the community pharmacy with its trusted, well qualified community pharmacist really is a godsend. Such pharmacies are the true gateway to the NHS and perform a vitally important role. Community pharmacists are the most accessible health professionals by virtue of long opening hours and ‘a no appointment necessary’ approach. In these times when 1 in 4 have to wait a week or more to see a GP, or can’t get an appointment at all, local pharmacies are often the sole provider of continuity of care and the pharmacist is too often the only familiar face in an overstretched primary care team. Most community pharmacies offer a free prescription collection and delivery service that ensures that housebound patients and busy working people get the medication that they need in a timely fashion. In addition for those who wish to self medicate, thereby saving the NHS money, community pharmacies provide conveniently located, free professional advice on full a range of OTC (over the counter) and POM ( pharmacy only medicines) and as such are often the first port of call for such patients.

    The Department of Health has made no secret of its efforts to reduce demand on the NHS and it is a fact that no health professional is better placed than the community pharmacist to promote healthy living and therefore the prevention of illness. Community pharmacists dispense thousands of prescriptions each month and every one presents the opportunity for a productive health intervention. In addition these pharmacies play a key role in reducing the number of hospital admissions and the support they provide for the elderly following discharge from hospital is crucial to minimise the risk of re-admission. The government should be trumpeting the advent of Healthy Living Pharmacies and working with the sector to further extend their role thereby supporting patients, reducing costs and easing pressure on other parts of the NHS.

    If community pharmacies close, and it was a Government minister who admitted these cuts could lead to up to 3,000 closing, where will all their patients go? They and their problems won’t just disappear. Some will pack out their GP surgery and others will head straight to A&E.
    The NHS is already in the throes of a staffing and funding crisis and forcing community pharmacies to cut back services and close down is short sighted in the extreme, and could have catastrophic in the long term.

    Labour knows the value of local pharmacies and so do all the communities across the country who rely on them. That’s why we’ve called this vote next week and I urge all responsible, discerning Tory MPs, whose constituents will be hit hard by these cuts, to vote with us.

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    WRITING in The Yorkshire Post over the summer, I warned about the devastating impact that Government cuts to pharmacies could have on our local communities and our NHS. And I invited the new Minister, David Mowat, to re-think the plan.

    In September, it seemed that the Government might be listening when the Minister told a conference of pharmacists that he was shelving the cuts programme so he could “spend the time… to make sure we are making the correct decision, and that what we do is right for you, right for the NHS and right for the public more generally”. Hear, hear, we said. Mowat was right to look again at this. After all, his predecessor as health minister, Alistair Burt, admitted that that up to 3,000 pharmacies – one in four of those across the country – could shut under the drive to slash millions from pharmacy budgets between now and April 2018. That could mean the closure of 300 chemists across Yorkshire and the Humber, forcing many frail and elderly people to make longer journeys to get the medicines and expert advice they need.

    The National Pharmacy Association has condemned them as a “dangerous experiment”. And the public made their opposition loud and clear when the largest ever healthcare petition – now signed by over 2.2 million people – was handed into Downing Street last May by cross-party campaigners and myself.

    But last week the Government announced it is pressing ahead with a bumper package of cuts that will reduce pharmacy funding by £113m for this financial year and by a further £95m in 2017-18 – a 22 per cent hike on the original £170m earmarked for cuts.

    Last week, I forced Mr Mowat to come to the House of Commons to answer an ‘urgent question’ from me about these cuts to the crucial frontline service provided by pharmacists. The Minister, a chartered accountant before he became a Tory MP, admitted that he just “didn’t know” how many pharmacies will close or which areas will be the worst hit. The Department of Health’s own impact assessment similarly stated that “there is no reliable way of estimating the number of pharmacies that may close as a result of this policy”.

    While such candour and clarity from Ministers is refreshing, it is appalling that the Government appears determined to drive through these cuts without any understanding – or thought – for the consequences.

    Equally, the Government was unable to say – when I asked them – what the downstream costs to other parts of the NHS might be if pharmacies closed.

    Evidence from Pharmacy Voice shows that one in four patients would seek a GP appointment if their local chemist faced closure. In areas of higher deprivation, like in my own Barnsley East constituency, that figure rises to four in five.

    This just piles on even more pressure on our already overstretched NHS at a time of another looming winter crisis. The Government claims to have come up with a ‘Pharmacy Access Scheme’ that is supposed to ease the impact of the cuts for pharmacies that are not in so-called ‘clusters’. But my research has found that only around one in 10 pharmacies nationwide are likely to be eligible for any help – and even those who do so will still have to make cuts.

    That’s why I am now demanding an urgent vote in Parliament against these cuts. If the Health Secretary Jeremy Hunt and his ministers are so confident that they have devised such a brilliant plan for our pharmacies, why not give MPs a vote on the issue?

    The reason is that they might just be in for a nasty shock. It’s not just Labour MPs who have supported the campaign about the threat to thousands of pharmacies. Several Tory MPs spoke out in the Commons last week against the cuts. Colne Valley Tory MP Jason McCartney compared the potential closures to the losses of the last bank branches in rural towns and villages. Of  the Government’s plan, he told Ministers: “I am sorry but I just do not have confidence in it.”

    In Yorkshire and the Humber, there are 1,266 community pharmacies that dispense almost 10,000 prescription items every month, as well as supporting public health and providing invaluable medical advice and support on a range of issues. Every pharmacy that is forced to shut its doors will mean hundreds of often frail and vulnerable people having to make longer and more expensive journeys to get the help they need.

    If Ministers are so confident that these cuts to community pharmacies are “the correct decision”, let’s have a vote in the House of Commons. But we should do so before it is too late and we see many of our pharmacies closed for good.

    This article first appeared in the Yorkshire Post 

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    The genesis of this talk was in the realisation that my ideas have changed over thirty years, and rightly so. The days when healthcare professionals told the public what they were graciously going to do for them have gone, I hope; and I see now that some of the things I used to think were completely wrong. In fact, they are so wrong that I have managed to come to this conclusion without the need for my wife to point it out to me.

    In 2000 I decided that I was fed up with doing training courses that lasted a few hours, and I wanted to do something more substantial, and I saw an advertisement in the British Medical Journal for a Master’s degree in medical law and ethics at Glasgow University. With my wife’s support – and how generous she has always been in supporting me – I completed the degree and graduated in 2003 as a Master of Philosophy. Incidentally, my graduation ceremony was in the first week of December in Glasgow, and after it the university laid on orange juice in their quadrangle gardens, an event marked by the guests clustering in tight groups trying to keep warm.

    Studying law changed the way I think. Any medical science is largely a collection of facts. Our exam questions are numerous but fairly short. Having to maintain an argument over essays of 5 to 20,000 words was a new skill I had to acquire, but a really valuable one, and it began right at the outset.

    One of the first topics we tackled was that of consent. As you will know, whenever you are faced with an operation, the doctors will ask you to sign a consent form. Things have changed, but when I worked there this was largely a box-ticking exercise, a step you had to go through in order to get your operation, and there were elements of the process that I could immediately see were unsatisfactory. Let me concentrate on three.

    First, we ask for your consent when we conduct surgery on you. After all, your surgeon is about to attack you with a knife, and as a judge noted as far back as 1913, that is a criminal offence that is only excused by the fact that you have agreed that he or she may do so. But have you ever been asked for your consent to receiving a medicine? We have assumed that you give your consent by turning up and asking for some kind of treatment; and you demonstrate continuing consent by taking the tablets. Except, of course, that a great many people do not take the tablets; a recent estimate was that £300 million in medicines goes unused in the UK each year. The authors of that report came up with five reasons for that waste:

    • Non Compliance – where the patient takes the medicines, but not in the intended way. For example, taking at irregular intervals or in incorrect doses.
    • Intentional Non Adherence – patient stops taking medication due to side effects or personal beliefs.
    • Unintentional Non Adherence – patient stops taking medicine due to forgetfulness.
    • Non-Preventable Waste – patient dies or a change in treatment means current dispensed medicines are no longer required.
    • Preventable Waste – patient stockpiles medicines “just in case”.

    But it seems a little unfair for us to complain about intentional non-adherence when the patient was never asked to agree to take the medicines in the first place.

    Second, an important and necessary step in obtaining consent is that all the possible alternatives are laid out for the patient. It is true that some patients find that unhelpful, because they do not feel equipped to choose between them. Many doctors report that patients say “What would you do?” or “Do whatever you think you should.” But that is not a reason to bypass this step. And too often it is omitted in talking about medicines with patients, and they do not complain. That is one reason why I think a bolshie patient is a good thing. It challenges us to give the explanation we ought to have given in the first place.

    To some extent the NHS recognises this. It has two free services for patients that pharmacies provide. The New Medicines Service involves talking to patients when a new medicine is dispensed for the first time, and twice more during the first month, because the evidence is that if a patient is going to deliberately stop it is likely to happen during the first month. It is a common experience that when you leave hospital a lot of things are said to you, sometimes when you’re just relieved to be going home, and it is hard for patients to retain and understand what was said. The New Medicines Service reinforces that information when, we hope, people are better placed to receive it. An evaluation by the University of Nottingham showed that the service increases the number of patients who correctly take a new medicine by around 16%. For existing medicines, there is the Medicines Use Review. Some people refuse these because they think their doctor is already doing it, but they are confusing two different things. The doctor carries out a clinical review – is this the right medicine for the condition this patient has? – but our Use Review looks at whether you understand how and why to take your medicines.

    Let me give you an example. We noticed that a gentleman ordered his blood pressure tablets every month, but did not always order his arthritis treatment. It turned out he had plenty left over. The reason was simple. The GP told him to take one with his supper, and some nights he didn’t have supper, so he didn’t take the tablet. When we explained that what the GP meant was to take it, but not to do so on an empty stomach, he took them more reliably.

    The third imperative is that whoever collects your consent should be able to answer your questions and give you a fair and complete account of the pros and cons of the treatment that is proposed. Now, here I think we may still have some work to do. The last time I was in hospital the job of getting my consent was given to a junior doctor, and you have to ask whether such a doctor is in a position to answer all the questions that we might have. It would, of course, meet the case if they start the process and then fetch someone else if there is a difficult question. But it is important that people should not feel pressured to sign until they have had all the explanation that they feel they need, and if that means being a bit bolshie, so be it.

    It is also important to note that any consent you give is a limited consent. It allows only what is specified, and we have moved away from the kind of consent form that says “Do whatever you want”. It is only sensible that for some operations we include a term that allows the surgeon to get on and fix something that he finds without having to stitch you up and then start again a couple of days later; and there is always the common law duty to act in your best interests which means that if you are unable to give your consent, we do whatever we think is best for you. I hesitate to mention this so soon after lunch, but it’s a good example. The very first operation I observed was for a man who was thought to have cancer of the penis and was going to have it amputated, but when the surgeon cut into the skin it became clear that actually it wasn’t a tumour, but a very large infected cyst. Now, the only thing the surgeon could do according to the consent form was to go ahead and amputate it anyway, but instead he drained the cyst and packed it with antibiotics. That’s what we thought the patient would prefer. On the other hand, there is a famous case, Perry v Shaw, where a surgeon was sued because having performed a tummy tuck on a lady, he used the spare material to give her an unexpected breast enlargement. She went to sleep as a 34B and woke up as a 40DD, and was unhappy about it, and his defence – “I thought she’d like it” – did not impress the judge.

    So here we have the first legitimate use of bolshieness – you should be fully informed of the options, the risks and benefits before you begin treatment, and if you are not, you are entitled to be politely stroppy.

    Let me expand on this a bit by referring to the work of NICE and other guidelines. NICE is such a big part of our lives that we forget that we have to explain why it is important to others. The National Institute for Health and Care Excellence weighs the evidence for each type of treatment and tells us what we should be doing. For example, if you have diabetes NICE will tell you that you should be offered at least six different drugs because you have an increased risk of stroke or heart attack. That does not mean that you must accept all six, or that your doctor will be failing you if he does not insist on all six.

    Let me explain why that is with some examples. One of our patients was given a statin when she left hospital. She is 89. She said the doctor told her it would prolong her life, but quite reasonably she asked me “How much difference can it make at my age? And, actually, I’m not sure I want to live longer.” My advice to her is that she is entitled to say to her doctor “Thanks, but no thanks.” So long as he is satisfied that she understands the implications, the GP will usually be happy simply to note that it was offered and refused. You’re an adult, and you’re entitled to say no. We had a lady who was given a water tablet for her high blood pressure, but because she wasn’t very mobile she had some accidents and decided she didn’t want it any more. She wasn’t too polite about how she expressed it to her doctor, and I doubt he could have put the tablets where she suggested anyway without some difficulty, but she was entitled to say no.

    Better that than that she should do what another patient did. She stopped taking her water tablets, but decided not to tell her doctor in case he was cross with her. When she developed fluid on her chest, he doubled the dose, except, of course, that now she didn’t take two tablets instead of taking one. She declined further and was admitted to hospital, where the doctors looked at the treatment she had been having and decided that if two tablets weren’t working they had better give four, but by injection because it was quite urgent now. Suddenly introducing a drug she hadn’t actually been taking proved fatal. So there you are; be bolshie, don’t be dead.

    People worry that their doctors will be cross with them if they argue or say no. They won’t – or, at least, the majority won’t and none of them have any right to be. After all, we regularly discuss with people at the ends of their lives how much treatment they want. It is not at all uncommon for them to say “Thanks, but I’d just like to stop the drip and go home now, and let nature take its course.” Nobody yells at them “But you’re going to die if you do that!” It’s their life, and they have every right to make that choice.

    Occasionally people will say “But life is a gift from God, and we have a duty to keep it as long as we can.” I observe, however, that if the fact that life is a gift from God trumped other considerations, St Paul would have told Christians to sign anything that meant they didn’t get martyred, and he didn’t. Given a choice between spending your Saturday afternoon in the garden and finishing up as a tasty snack for a lion, I know which way my vote would be cast.

    I may add that if you decline treatment, you do not have to give a reason. It’s nice to know, just so we are confident it isn’t because we have misled or confused you, but you are not obliged to share it. In a famous legal judgment known as re T, Lord Donaldson said “An adult patient who … suffers from no mental incapacity has an absolute right to choose whether to consent to medical treatment …. This right of choice is not limited to decisions which others might regard as sensible. It exists notwithstanding that the reasons for making the choice are rational, irrational, unknown or even non-existent.”

    The other observation I ought to make is that the relationship between a patient and their pharmacist – or other healthcare professional – depends to a great extent upon trust. I am aware that like Mary Bennet in Pride and Prejudice, I may shortly be told that I have delighted you long enough, or I might continue at length about the grounds of trust. It matters because there have been several recent books pointing to an erosion of that trust. In fact, in many cases when we give consent, we give it not because of any rational argument we have weighed, but because at bottom we trust the professional concerned. Why do we do so?

    There is an argument that trust derives from the professional standing. We trust doctors generally, even if we have not met them before, because we know that they have taken an oath to do their best for us. We know that they face professional sanctions if they do not do so. And we know of no reason why they would wish us any ill-will. Dr Shipman did not do a lot for that last argument, of course, but I worked on the aftermath of his crimes and it was remarkable that even after he had been convicted a lot of people in Greater Manchester still thought highly of him. It was easy to find people who believed that there must be some other explanation for the death of nearly a tenth of his patients.

    This general trust – trust of a class of people – is one reason why some of my colleagues, particularly those who work for pharmacy chains, will argue that it doesn’t matter if you see a different pharmacist each time because they all work to the same procedures and protocols, and are bound by the same standards. All that is true, but our experience of this wonderful city and its people is that they prize the continuity of seeing a familiar face. They trust us, and they forgive us our mistakes because they know we are not indifferent to them.

    I recently read an excellent little book by Professor Katherine Hawley, from the University of St Andrews, on the subject of trust, in which she points out that it would be impossible to live a life without trust. How could we sleep if we did not trust our partners not to put a pillow over our faces during the night? What could we eat if we did not trust that our supper was not poisoned?

    And what is that trust built upon? It is built upon predictability. We trust because we believe that we know what the person we are trusting will do (or not do). I trust that Gillian will not strangle me in bed, because she never has, despite, no doubt, considerable provocation. I trust that she will not put deadly nightshade in my salad because it hasn’t happened yet. That is why lost trust is so hard to regain – once you haven’t behaved as predicted, how can anyone predict what you will do yet? It is, of course, possible to be predictably unreliable. David Niven once said of Errol Flynn that he was completely predictable, because he always let you down, so you never depended on him. But in our business we try to earn your trust, and to keep it once we have it, by relentlessly doing our best.

    One of the delights of being in practice here for so long is that we have seen a whole generation pass through our hands. We have seen babies born who now have babies of their own; we have cared for people who were still vigorous and active, but who have become frail and dependent. We have been much blessed, personally and professionally, but we are very aware of Luke 12:48 and its reminder that much is demanded of those to whom much is given. You taxpayers paid for our education and we have been trying for nearly forty years to repay that debt in some small way.

    To close: the celebrated management writer Robert Heller published a book in the eighties which mentioned my then employers, Allen & Hanburys, along with a group of others that had survived over 250 years – Barclays, Lloyds, Fry’s, Rowntrees, Terry’s to name but a few. Apart from a concentration on banking and chocolate, why had they survived when others did not, he asked? And he concluded that their Quaker beginnings had played a large part. Allen & Hanburys was also a Quaker firm and Heller argued that their belief in a duty to give their customers full weight at a fair price, to trade for the lifetime rather than the moment, was what enabled them to keep going. In short, they were trusted; perhaps less so now, but still more than some others. That’s how important trust is.

    The person others might describe as a bolshie patient we see as someone who is simply trying to look after their own interests. We need more of them, because if I can’t convince you to do what I think is best, I have no right to demand it of you.

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    We don’t want more access to services, we want access to better services; more planned and less walk-in care; policies that promote patient-professional relationships; and systems shaped by clinical need rather than financial or managerial considerations.

    1. I have long been opposed to patient lists for pharmacies. My feeling is that having to ensure people come back because they want to encourages good service. But the modern advanced services such as Medicines Use Review and the New Medicines Service only work well if we have patient lists, and it’s very hard to drive standards up if we have no denominator for uptake of services. For these reasons I think we should encourage patients to develop a relationship with their local pharmacy and a list system could drive that.
    2. NHS Pharmaceutical Services are more than just dispensing. The recent hub and spoke consultation and what a friend calls the Amazonisation of dispensing shows that even NHS England don’t understand this. In fact, separating dispensing from good advice services is a profoundly stupid move and we need a commitment to tying the two together. Dispensing factories might be popular with patients but they are losing something by using them – and they put strain on the rest of us. I spend a lot of time now dealing with people who want advice about medicines they’ve had dispensed elsewhere (and of course I can’t answer a lot of the questions, nor should I be expected to do so free of charge).
    3. It follows from 2 that the position of dispensing doctors can’t be ignored any longer. I have no particular dislike of them, and some of them have high standards, but certainly general GP services should not be subsidised from dispensing. I have no doubt that GPs are overworked, but it’s interesting that I never hear one say that they could do with getting rid of dispensing. Their core purpose is to diagnose and there is no point in putting pharmacists into practices to do clinical work when doctors are still dispensing. Accordingly, there should be a long-term plan to remove the need for dispensing practices and ensure that a full range of pharmaceutical services are available to everyone equally.
    4. Hospitals have been creating outsourced outpatient dispensaries as a means of avoiding VAT – in fact, some of them aren’t HMRC-compliant and it may not work for them, but it cannot be right that the service patients get is being shaped by a tax liability rather than a clinical need. We need an inquiry into how this could be avoided. Some patients are being allocated to homecare for the same reason.
    5. Manpower planning under the current government is being left to the market. The problem is that we’ve got a pre-registration bottleneck. Taking a pre-registration student is an expensive business and the current payment is inadequate – but, more to the point, we need proper assessment of manpower needs and provision, probably in all the healthcare professions.
    6. The last Labour government championed access, pushing for walk-in centres and increasing the number of pharmacies dramatically. This was an expensive policy and the Tories are now reversing it, but using market forces rather than good planning to achieve it. The likely result is that rural pharmacies (which are more likely to be independents) will suffer while the urban ones (which are allegedly the government’s target) will have deeper pockets and be parts of chains which can cross-subsidise. There is a philosophical point hidden in this: it gave patients the idea that each encounter with a healthcare professional could be self-contained. From this, it followed that providers have argued that it doesn’t matter if they run pharmacies entirely with locums, or change staff frequently, because so long as their procedure manual is followed the patient will get the same care. However, my experience of 36 years as a community pharmacist is that the enduring personal relationship improves patient care. I’m sure the same will be true of GPs. It also happens to be what patients say they want. For example, we have a patient whom we’ve just persuaded to have a memory assessment. She’s relatively young, but we can see she has suddenly become very vague. If we hadn’t know her for years, we wouldn’t have spotted that. So we need to ensure that policies promote patient-HCP relationships and that providers are inhibited from changing staff frequently. Including some element of “continuity payment” in the contracts may help here.
    7. Community pharmacists have had real trouble getting accepted onto prescribing courses. I managed it, but only because I was also working for the PCT at the time. The argument was that I didn’t have access to a prescribing budget, but it’s chicken and egg. If I could prescribe, I could then apply for work that required some prescribing. We need to drive for all pharmacists to become prescribers in the long run – included in undergraduate courses and with access to courses for those already in practice.
    8. Dr Charles Alessi, who is big in the NHS Commissioning world, argues that the future is for GPs to diagnose and monitor, with pharmacists adjusting therapy in long term conditions. That’s not a bad model to aim at. It could take workload off GPs and thus allow them to accept some load back from specialist services and consultants. For example, our local rheumatologist says – and the evidence backs him up – that the key to successful treatment of rheumatoid arthritis is to see patients within 6 months of diagnosis, ideally within 3. He can’t do that at present because his clinics are full of people coming back for their treatment which he could pass back to GPs if they were happy to prescribe DMARDs. This calls for mutual backscratching. If GPs will prescribe DMARDs under shared care, the consultant can give their patients better care. It’s common sense, but it founders on the insistence of some GPs that they are not going to take part because “consultants should be doing this”. They have the right not to join in shared care – my view is that if a local medical committee thinks a shared care arrangement is acceptable, the norm should be that all GPs will join it. They shouldn’t be able to say no – “not yet” is an acceptable answer if there are educational needs to meet, but an action plan should be produced specifying when they will join in. The relevance to pharmacy is that primary care shared care could be from consultant to pharmacist on some occasions.
    9. There are some very innovative pharmacists in the community. However, implementing their plans requires that they persuade their local NHS England or CCG, and some won’t even look at plans, even when they’re cost-sparing. We need a central “suggestion box” system with a royalty payment on uptake.
    10. The Drug Tariff is a daft way of managing drug costs. Too often we’re having to buy products at prices above the reimbursement cost and make a loss. The NHSBSA Pacific Programme is being steered by a vocal group (including me) to look at this rather than tinker at the edges. But the current government’s mania for driving drug prices down simply means that we get shortages because some companies stop making things when the price is too low. NICE handles new drug cost-effectiveness, and the Pharmaceutical Price Regulation Scheme is meant to deal with existing drugs, but it’s not working well, and a small number of companies are gaming the system to make unreasonable profits out of key medicines. The whole approach to drug pricing has to look at developing a drug industry that contributes through increased taxes (because they’re making healthy profits) rather than reduced prices.
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    NHS England has announced  that local councils will be responsible for funding the new HIV treatment PrEP.

    This is a missed opportunity to launch a ground-breaking prevention method that could halt the spread of HIV, potentially save lives, and make a significant breakthrough in reducing the risk of HIV infection. Councils have invested millions in providing sexual health services since taking over responsibility for public health three years ago, and this treatment could help reduce levels of HIV in the community.

    It is also not right that councils should be made to foot the bill. In stating that local authorities are responsible for commissioning HIV prevention, NHS England adopts what is, in our view, a wholly inadequate position.

    During the transition period to implementation of the NHS and Care Act 2010, NHS England sought to retain commissioning of HIV therapeutics, which the PrEP treatment clearly falls into.  It is, and should remain, an NHS responsibility unless it is fully funded for local authorities to pass on.

    NHS England’s statement is a selective and untenable reading of the Public Health Regulations 2013 and an attempt to create a new and unfunded burden on local authorities.

     

     

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    Funding cuts could force hundreds of local pharmacies to close, cutting off a vital lifeline for elderly and vulnerable people and leaving some facing long journeys to collect essential medicines, councils warn today.

    The Local Government Association (LGA), which represents more than 370 councils – who have responsibility for public health – is warning a £170 million reduction in NHS funding for community pharmacies could put many out of business.

    In its response to the Department of Health’s consultation over proposals to instead use clinical pharmacists in primary care settings such as GP practices, the LGA insists local pharmacies must remain at the heart of communities, rather than risk bringing more people to surgeries and adding to existing pressures.

    The LGA says the closure of community pharmacies could leave many isolated and vulnerable residents, particularly in deprived areas, struggling to access pharmacies for their potentially life-saving medicines.

    For some people the local pharmacy is their only contact with a health professional, providing access to invaluable health advice and enabling older people to live more independently.

    A bigger role for community pharmacies would instead help take away some of the strain from hospitals and GP practices. Local pharmacies should be expanded within their communities, say councils, providing important public health services such as health checks, smoking cessation, sexual health, screening and immunisations, in addition to dispensing and selling medicines.

    Pharmacies should modernise, with new ways of ordering prescriptions and collecting medicines, including online ordering and delivery to the patient’s home.

    Community pharmacies are also vital to ensure diverse and vibrant high streets, which can otherwise be dominated by betting shops, fast food outlets and payday lenders. The LGA said vacancy rates have doubled in recent years, with the amount of money shoppers are spending halved and insisted local pharmacies must remain at the heart of communities.

    Cllr Izzi Seccombe, LGA Community Wellbeing spokeswoman, said:

    “Maintaining community pharmacies is crucial to keeping older and frail people independent. They need to be at the heart of communities, close to where people shop, work and go about their daily lives, rather than the heart of the NHS.

    “For many elderly people, their local pharmacist is not just a dispenser of medicines, but someone who they know and look to for informal health advice and information. Vulnerable and elderly people should never be forced to travel potentially long distances to pick up vital medicines and receive health advice.

    “Community pharmacies do need to change but the cuts in funding could lead to many being forced to close. They should actually play a bigger role in providing public health services, alongside their important existing roles of supplying medicines. Additional investment in community pharmacies could improve the prevention of disease and access to health services. They can also help contribute to thriving high streets.

    “Being at the heart of communities means pharmacies see people in every state of health and are ideally placed to play a central role in the prevention of illness, which can reduce costs and pressures on the NHS and adult social care.”

    Case studies of how pharmacies are playing a vital role in communities

    Lincolnshire – co-location of library, pharmacy and post office

    In November 2012, the library in Waddington moved into the Lincolnshire Co-operative pharmacy, with the aim of creating a community hub of key village services. The site also includes a post office. £70,000 investment provided a distinct library section featuring 4,000 books, a photocopier, self-issue technology, two internet computers, an enquiries desk and seating areas. The pharmacy was also refurbished, including new seating and a new consultation area. The new arrangements mean that people in the village can borrow books during the pharmacy’s opening hours, whereas previously the library was only open for 14 hours a week. This model brings together on one site three of the key local sources of information, advice and signposting and in so doing, increases their likelihood of survival.

    Hampshire – pharmacy-based chlamydia screening, treatment and emergency contraception provision

    Community pharmacies in Hampshire are delivering a range of local authority commissioned sexual health services including chlamydia screening kits for 16 to 24 year olds, free condoms for 13 to 24 year olds and antibiotic treatment of chlamydia.

    Norfolk – community-based physical activity supported by community pharmacy

    In Norfolk, community pharmacies have been working with national and local sports organisations to develop a series of community walking groups and community activities to encourage physical activity for people aged 50 and over. The programme is promoted through community pharmacies in conjunction with lifestyle advice and health services such as cholesterol testing and health checks and Medicine Use Reviews. The programme builds on the expertise and accessibility of community pharmacy to support people to make informed choices about their health and wellbeing.

     

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    The minimum practice income guarantee is set to make headlines again this year, as GPs and patients in Wales begin to see the effect of its withdrawal.

    The minimum practice income guarantee (MPIG), which is variously described as a ‘correction factor’ or ‘compensation payment’ for small practices, is being phased out over seven years in Wales from 2015 despite doctors’ lobby for maintaining the MPIG’s protective and stabilising effect on the finances of small practices, including those located in rural areas.

    According to BMA Cymru (Wales), which represents doctors in Wales, around 40% of practices will see reduced income as a result of the MPIG withdrawal – on average by around £5,000 a year per year. As the BMA has accepted in its communications to GPs, “affected practices will have to make some difficult business decisions in order to absorb these losses”. English practices know all too well about these difficult business decisions. The process of removing MPIG from GP funding in England started in 2014, and already it has attracted significant political opposition. In February, 2014, South Lakes MP Tim Farron called for Parliamentary debate about rural GP funding following concern about the risk to smaller local surgeries caused by the MPIG withdrawal, and the effect closures could have on patients.

    Delivering on rural promises

    In its 2012 Rural Statement , the Government restated its commitment to rural England, focusing on three objectives:

    • economic growth – rural businesses can make a contribution to national growth
    • quality of life – people living in rural areas have fair access to public services
    • talking directly to rural communities – political empathy with rural areas.

    NHS Pharmaceutical Services policy in England, Wales and Scotland dictates the framework and, in part, the funding for dispensing GPs, which as a group provide primary medical and pharmaceutical services in Britain’s most rural areas. It is the position of their representative organisation, the Dispensing Doctors’ Association, that the current regulatory and financial  arrangements for rural GPs fail to deliver on the promises made by Government in its 2012 rural statement, for the following reasons:

    1) economic growth: in 2012 the Welsh Assembly concluded that “the cost factors incorporated into funding formulae can be too low, and so fail to accurately account for the costs of rural service provision”. For the rural GP practice these costs may include the increased costs of transportation (home visits) and supplies (low volume surcharges), staffing costs (incentivised recruitment) and provision of a wider range of healthcare services that acknowledges the lack of other local healthcare service providers. In dispensing practices routinely reinvest the profits from the dispensing activity to cross-subsidise the increased costs of providing rural general medical services. In hard to staff areas, dispensing income is also used to incentivise GP recruitment and retention. This phenomenon was only publicly acknowledged for the first time in 2014 and at the time of writing, the principle is yet to be embedded in either rural GMS funding or in the remuneration/reimbursement processes for the GP dispensing activity

    2) rural patient engagement: When patients are eligible to choose to receive dispensing services from their GP the overwhelming majority choose to do so. A 2008 Patient Survey by the Dispensing Doctors’ Association demonstrates patients’ preference for GP dispensing services. However, in England patient eligibility for the GP dispensing service takes no account of patient choice. Only last year (2014), Scotland passed new regulations affecting dispensing practice, which acknowledged prior shortcomings in the dispensing patient engagement process. It is yet to be seen how the new regulations will improve the patient engagement process.

    3) Equitable service provision: Throughout Britain rural patients are denied services that are available to urban patients who access pharmacies. Pharmacy services currently unavailable to rural patients using dispensing practices include: the electronic prescription service, the new medicines service, the medicines use review service, and the chronic medication service. The untapped economic potential of rural areas is said to be worth an extra £347 billion per annum to the national economy, if only more policies supported rural economic development. Defra has made this issue its top priority and has launched a number of schemes aimed at growing the rural economy.

    Rural GPs would urge the NHS to follow Defra’s example, and allow rural medical services to play their full part in the development of Britain’s countryside areas.

    Dr Richard West is chairman of the  Dispensing Doctors’ Association

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    As the election campaign begins in earnest, the NHS has become one of the key areas over which the political parties will attempt to persuade the voters that they are best to protect, what Nigel Lawson once called the closest thing we have to a religion.

    More often than not when politicians refer to the NHS, they almost always mean the hospitals and GP surgeries in towns and cities.  As a result, much of the analysis and policy is urban-centric.  For the eight million patients of dispensing practices, which can only be found in rural areas, and the doctors who provide the service, this can become a little wearing.

    Rural surgery

    Dispense practices pre-date the NHS and can be traced back to the introduction of National Insurance in 1911.  They exist only in rural areas where a community pharmacy is not economically viable.

    What might be a wonderful solution to the problems of urban areas, like federating practices for example, may not necessarily be of any practical use in a vast area of remote and rural Britain where the population is sparse, the transport network is less well developed and 3G and superfast broadband are just the stuff of glitzy TV and newspaper advertisements.

    The challenges of providing GP services in rural Britain are not just limited to its geography.  There tend to be more elderly patients with chronic diseases, who do not necessarily want to receive an appointment at 8pm during the week, or a Skype consultation.  For them, and for many rural patients, the local surgery is at the centre of the community and does not just offer them their GP service.  In addition, deprivation is more difficult to find and deal with and is often not accurately reflected in the NHS funding formula for practices in rural areas.

    Rural practices also dispense medicines to their patients, where a pharmacy is not economically viable in the area.  This highly popular, one-stop-shop service also subsidises the provision of the GP service, when it might not otherwise be viable.  As NHS GP budgets continue to be squeezed through austerity, it is the dispensing service which keeps rural practice afloat.  Many people are unaware of this and assume that the service will continue to be there because it always has been.

    As the recent TV and newspaper stories demonstrate, the NHS is under unprecedented pressure due to patient demand and the lowest increase in the budget since its inception.  GP surgeries are finding it increasingly difficult to recruit young doctors and the NHS review of practice funding disproportionately affects rural practices.  Taken together, these represent a daunting challenge for whichever of the parties forms a Government after 7th May.

    The Dispensing Doctor’s Association (DDA), of which I am Chief Executive, has launch a Manifesto designed to alert candidates from all parties, and their communities, to the importance of dispensing GP practices.  They are the hub from which health and social services should be delivered in the future and, if local health economies are not to be destabilised further, they must be preserved and invested in over the next five to ten years.

    As the NHS Five Year Forward View says:  “Smaller independent practices will continue in their current form where patients and GPs want that.”[1] 

    The DDA agrees and would like to see practices have:

    • access to superfast broadband
    • access to the Electronic Prescription Service (EPS), which is not currently available for dispensing practices.
    • district and social services teams based in rural practices, not miles away in the nearest town.
    • community pharmacists as part of the practice team, helping to manage chronic diseases and medicines optimisation.

    Taken together, these developments will see pressure removed from local district general hospitals providing my patient-centred care, closer to home as the NHS Five Year Forward View envisages.

    The DDA encourages all candidates to visit their local dispensing practices during the election campaign.  Only by meeting the patients and the healthcare team will candidates see for themselves the vitally important, and often unsung, role of the dispensing doctor practice.

    Dispensing Doctors’ Association

    1 NHS Five Year Forward View NHS England, October 2014, p19.

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