NHS GRAMPIAN

Review of continued dispensing from the Haddo Medical Group following the opinion of Lord Doherty

1.Actions Recommended

The Board is required to accept, reject or amend the recommendations of the Review Group set up to considerthe continued provision of dispensing from the Haddo Medical Group. This latest review is a consequence of Lord Doherty's Judicial Review findings against NHS Grampian, published on 9th September 2014, in respect of the decision to allow continued dispensing of medicines by the Haddo Medical Group for patients living in all areas except that covered by the Tarves neighbourhood.

  1. It is recommended 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 difficultly 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.

  1. It is recommended that prior to implementing this decision NHS Grampian should:

a)Undertake an impact assessment of implementing therecommended limitation on dispensing, by the Haddo Medical Group, to the delivery of General Medical Services to the area and any consequencesthis 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.

  1. It is further recommended thatNHS 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.

2.Strategic Context

The norm in primary care in Scotland, along with the rest of the UK, is that General Practitionersprescribe medicines and community pharmacies dispense those prescribed medicines. This norm is supported by the regulatory framework applicable to both General Medical Services and Pharmaceutical Services.

In some parts of rural Scotland, the NHS relies on dispensing doctors toprovide dispensing services to their own patients who are unable to secure the dispensing services of a communitypharmacy. In these cases the dispensing doctor service plays a vital role inthe provision of NHS medicines. Scottish Government has recently amended the control of entry regulations, governing the award of new community pharmacy contracts in Scotland, to include an assessment of the impact of a proposed new pharmacy on existing NHS service provision, specifically including the impact on dispensing doctor practices. These amendments do not apply retrospectively to situations such as this, where the pharmacy is already established.

The Haddo Medical Group has a long history of dispensing medicines to its patients living in and around its main surgery in Pitmedden and satellite surgeries at Tarves and Methlick. This dispensing has taken place at the request of the NHS Board which considered that patients living in these areas historically had a serious difficulty in accessing prescribed medicines from a pharmacy.

NHS Grampian originally reviewed the continued provision of dispensing from the Haddo Medical Group following the opening of Tarves Pharmacy in early 2012 and again later that year. This new review is a consequence of Lord Doherty's Judicial Review findings against NHS Grampian, published on 9th September 2014, in respect of the decision to allow continued dispensing of medicines by the Haddo Medical Group for patients living in all areas except that covered by the Tarves neighbourhood.

Lord Doherty's findings focused on two areas:

a) The decision was unlawful in not providing Tarves Pharmacy with the opportunity to represent itself at the review panel 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 of the Tarves neighbourhood despite the review panel finding that only a proportion of individuals in that population had a serious difficulty of access to a pharmacy.

NHS Grampian has to decide whether patients who currently get, or are eligible to get, their dispensed medicines from the GP practices at Pitmedden or Methlick have a serious difficulty in accessing dispensed medicines from a community pharmacy.

The National Health Service Regulations covering General Medical Services only permit NHS Grampian to request Haddo Medical Group to dispense for its patients where, after consultation with the Area Pharmaceutical Committee, it is "satisfied that a person, by reason of -

(a) distance;

(b) inadequacy of means of communication; or

(c) other exceptional circumstances,

will have serious difficulty in obtaining from a pharmacist any drugs, medicines or appliances, other than scheduled drugs, required for that person's treatment..."

  1. Key matters relevant to recommendation

Legal Authority: NHS Grampian can only act within the legal authority available to it as laid out under the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004 Paragraph 44 of Part 3. This authority is clearly limited to the assessment of serious difficulty and does not extend to the potential impact of any associated decision to restrict or end dispensing services from the general practice, regardless of how long such arrangements have been in place or the nature of the impact. To do otherwise would expose the decision to further judicial challenge which NHS Grampian could expect to lose if it had allowed factors to influence its decision making that were not permissible under the regulations.

Potential for impact on General Medical Services: The Haddo Medical Group, when previously given notice to cease dispensing for patients living in and around Pitmedden, sought to close the satellite surgery at Tarves due to the resulting financial impact from loss of dispensing income to the Group. The impact of the decision to restrict dispensing on the Haddo Medical Group will need to be considered to assure the Board that NHS Grampian continues to discharge its responsibilities for the provision of General Medical Services to the local population.

Operational difficulties in applying the decision: There may be a number of operational difficulties in applying the decision which will require to be addressed e.g. the ability of the Haddo Medical Group to provide the services requested by the Board from the more limited income stream associated with dispensing in the future, the need for guidance to support the practice and patients in ensuring that the Haddo Medical Group only dispense to patients under the authority provided.

Timescale of implementation: Normally NHS Grampian would provide 12 months notice to a practice to cease dispensing for patients in order to allow for a managed takeover of patients and the run down of stock that the practice had invested in. Given the long period of time that has taken place since the opening of the pharmacy in Tarves, the previous 12 month period of notice applied to an earlier decision and the delays due to the Judicial Review it should be noted that any delay in implementing the decision should be avoided insofar as reasonably practicable.

Wider review of dispensing practices in NHS Grampian: NHS Grampian is committed to a review of dispensing practices in NHS Grampian. The planning of this review started in 2013 but it became clear that there was a strong risk of legal proceedings being brought against NHS Grampian with regard to its Haddo decision. It was felt that to undertake the wider review whilst there was a risk that the Haddo decision was to be challenged would be inappropriate.

NHS Grampian would have liked to have reviewed the Haddo decision as part of this wider review. However, the urgency and timescale of decision making has been driven, to a large extent, by Lord Doherty’s By Order hearing, which went ahead on 7th October 2014. The purpose of the By Order was to satisfy Lord Doherty that the Health Board was taking appropriate steps to revisit its earlier decision in light of the court’s ruling. At the Judicial Review of NHS Grampian’s previous decision Lord Doherty granted declaratory of unlawfulness but refrained from immediately granting decree of reduction which he recognised would give rise to administrative difficulties for NHS Grampian and the Haddo Medical Group. Legal advice indicated that an extended timescale to allow consideration of the decision as part of a wider review risked being seen as too lengthy. It was considered that this carried the risk that at the By-Order hearing the extant decision of NHS Grampian to allow continuation of dispensing by the Haddo Medical Group would be rolled back to the previous decision to cease dispensing for Pitmedden patients. Legal advice was that this would lead to cessation of dispensing for Pitmedden patients with immediate effect whilst the Board undertook its wider review. NHS Grampian took the view that the disruption to patient care and the impact on the GP practice, particularly in the event of ceasing dispensing and then having to restart at a later date, were not in the best interest of any of the parties involved.

Risk of further challenge: There may well be further challenge to this decision given the history and strong feeling among some members of the local population and their representatives.

  1. Risk Mitigation

The key risk mitigated by implementation of this decision will be to have revisited a decision that was deemed unlawful and in doing so complied with the judicial requirements placed on NHS Grampian in line with the extant regulations.

5.Responsible Executive Director and contact for further information

If you require any further information in advance of the Board meeting please contact:

Responsible Executive Director
Dr Nicholas Fluck
Medical Director
/ Contact for further information
David Pfleger
Director of Pharmacy & Medicines Management

9 January 2015

Additional supporting information

Board members may on request be provided access to the supporting papers provided to the Review Group including:

  • Public Consultation Responses
  • General Population Health Status – Health and Wellbeing Profiles
  • Travel Information and Mapping
  • The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004
  • Aberdeen CHP Pharmaceutical Care Service Plan
  • Pharmacy and GP Practice Lists
  • Written submissions by interested parties and presentations
  • Judicial Review decision by Lord Doherty

Key milestones in the review of dispensing from the Haddo Medical Group and provision of pharmaceutical services from Tarves and Pitmedden.

  1. NHS Grampian has historically required the Haddo Medical Group to provide dispensing services as it had agreed that patients using the main practice in Pitmedden and the satellite practices in Tarves and Methlick had serious difficulty in accessing prescribed medicines from a pharmacist.
  2. NHS Grampian originally rejected an application for a new pharmacy in Tarves in December 2010, but that decision was overturned by the National Appeal Panel in June 2011 (available under hearings at:
  1. NHS Grampian also rejected an application for a new pharmacy in Pitmedden in December 2010
  2. An appeal by the applicants for the pharmacy at Pitmedden to the National Appeal Panel was dismissed in April 2011. (available under hearings at:
  1. In light of the opening of the new pharmacy at Tarves in December 2011, NHS Grampian reviewed its requirement for dispensing by the Haddo Medical Group. In early 2012 Haddo Medical Group were given 12 month’s notice to cease dispensing services to registered patients living within the neighbourhood of the pharmacy, as defined by the National Appeal Panel. This cessation was in line with the NHS Grampian protocol in place at the time.
  2. Soon after communication of this decision NHS Grampian received feedback from the pharmacy contractor in Tarves. This challenged the legality of using the neighbourhood of the pharmacy to define patients who no longer have serious difficulty in accessing prescribed medicines from a pharmacist. Following advice from the Central Legal Office it was agreed that NHS Grampian would revisit the decision as to which, if any, patients registered with Haddo Medical Group should continue to receive dispensing services from the GP practice. This advice confirmed that whilst in applying for an NHS community pharmacy contract there was a need to demonstrate inadequacy of services in a neighbourhood; this neighbourhood did not define the area to which the pharmacy could be deemed to provide services.
  3. In revisiting the original decision NHS Grampian undertook significant stakeholder engagement. The main stakeholders – patients, public, public representatives, Independent General Practice & Independent Community Pharmacy contractors were consulted with representations, letters and survey reports made available to the Decision Making Group. The review concluded that the new community pharmacy took away any difficulties in obtaining medicines in Tarves and that there was no serious difficulty of access to pharmaceutical services for patients living in and around Pitmedden. The recommendation was presented to, and accepted by, the NHS Grampian Board at its April 2012 meeting.
  4. April 2012 Board papers Item 8 available at:
  5. April 2012 Board minutes available at:
  6. Following the April 2012 Board meeting NHS Grampian communicated the NHS Board’s decision to the Haddo Medical Group and further definition of the boundaries of continued dispensing for patients living in and around Methlick was undertaken by Community Health Partnership representatives and the Haddo Medical Group.
  7. Following the notice to discontinue dispensing for patients living in and around Tarves and Pitmedden, the Haddo Medical Group, which is an independent contractor, notified NHS Grampian of its intention to close the branch surgery in Tarves. This was reluctantly supported by NHS Grampian as there was felt to be no other viable option and that whilst the geographical points of access to General Medical Services offered by the Haddo Medical Group were changing the services themselves remained the same.
  8. The decision by the Haddo Medical Group to close its Tarves branch surgery was a result of the cross subsidisation of their general medical services from dispensing income. From an NHS Board perspective the financial support for dispensing by general practice was put in place to cover the additional costs of providing dispensed medicines for registered patients. Dispensing by general practice was not envisaged to provide a net financial benefit to a practice. Aberdeenshire Community Health Partnership worked with the practice to explore the financial impact of the loss of dispensing income and associated risks to the services they provide. Unfortunately, without the additional income generated by dispensing, the practice had to review the services it could provide in order to achieve financial balance. This led to their decision to close the Tarves branch surgery.
  9. A series of meetings continued to take place with key stakeholders and the community following the receipt of the practice’s notification that it intended to close the branch surgery at Tarves. A meeting in September 2012, which was hosted by the Rt Hon Alex Salmond MSP with representatives of NHS Grampian, the community councils and the local community focused on concerns of some of those present that the Board had failed to assess serious difficulty of access appropriately and that circumstances had changed since the decision to restrict dispensing was made. NHS Grampian agreed to work with the representatives of the community, Community Councils and other interested stakeholders to clarify issues raised at the meeting. NHS Grampian agreed that the concerns raised at the meeting justified a further review of the decision to restrict dispensing for patients of the Haddo Medical Group.
  10. NHS Grampian held a further meeting with the Rt Hon Alex Salmond MSP and representatives of the community councils in October 2012 to support the community councils in clarifying their challenge to the NHS Grampian decision to restrict dispensing by the Haddo Medical Group.
  11. A new review panel met on 22nd November 2012 and the community councils were offered the opportunity to present their case to the panel meeting. The Review Panel considered all of the evidence presented to it and accepted that the Community Councils’ presented new evidence demonstrated serious difficulty by reason of inadequacy of means of communication. (Interpreted by the Review Panel around the provision of public transport for a proportion of the Pitmedden Community.)
  12. The Review Panel recommended that the Board, in light of new evidence, reconsidered its April 2012 decision and recommended that the Haddo Medical Group continued to dispense NHS prescriptions to its practice population with the exception of the Tarves neighbourhood, which was defined by the National Appeal Panel as the village of Tarves surrounded on all sides by agricultural green land.
  13. At its meeting of 4th December 2012, Grampian NHS Board accepted this recommendation. Papers available at
  14. There was also agreement at the 4th December Board meeting that a wider review of difficulty of access to pharmaceutical services would be undertaken as part of the Board's pharmaceutical care service planning process. This review was planned to begin later in 2013 to include consideration of existing arrangements where the NHS Board have requested dispensing by GP practices and the designation of some community pharmacies as essential under the Essential Small Pharmacy Scheme. These reviews would be led by the relevant Community Health Partnerships.
  15. Reinstatement of dispensing by the Haddo Medical Group for patients living in and around Pitmedden was followed by the Practice reopening its satellite surgery in Tarves.
  16. On 27th May 2013, NHS Grampian considered an application to provide new NHS Pharmacy Services from a proposed pharmacy in Pitmedden, to be located within the premises of the Haddo Medical Group. This application was made by the community led B999 Health Trust. This application was considered in line with the Scottish Pharmaceutical Service Regulations.
  17. The application for new pharmacy services in Pitmedden was turned down on the basis that there were adequate pharmacy services already available to those living in Pitmedden. NHS Grampian also concluded that the area could not support another pharmacy as this would put the sustainability and viability of existing NHS pharmacy services at risk. The full minute of the hearing on 27th May is available at
  18. This decision was appealed by the B999 Health Trust but the National Appeal Panel rejected the appeal on the 7th October 2013.
  19. In summer of 2014 a Judicial Review of the Grampian decision to allow continued dispensing for patients of the Haddo Medical Group was heard. NHS Grampian lost the Judicial Review. The report of the decision of Lord Doherty is available at:

https://www.scotcourts.gov.uk/search-judgments/judgment?id=5f1fa8a6-8980-69d2-b500-ff0000d74aa7