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Dispensing - It is all a question of rurality

The proposed abolition of practice boundaries will mean a more uncertain future for GP dispensing practices and their patients, writes Dr Jeremy Phipps.

Deemed rural: it is essential that dispensing practices keep up to date on which areas their PCTs define as rural or non-rural, otherwise their dispensing list size could fall (Photograph: Istock)
Deemed rural: it is essential that dispensing practices keep up to date on which areas their PCTs define as rural or non-rural, otherwise their dispensing list size could fall (Photograph: Istock)

GPs may dispense medicines only if certain criteria are met and, under the NHS Act 1977, distribution of NHS medicines to patients by community pharmacies is the norm.

Living at least 1.6km from the nearest pharmacy is the best-known criterion for GP dispensing, but patients must also live in a rural location, known as a 'controlled area'. This stops urban practices from dispensing to their patients, even if they live more than 1.6km from a pharmacy.

In England, as part of the current requirement for PCTs to update pharmaceutical needs assessments (PNAs), they must include a map detailing which areas are deemed rural and which are not. The map should specify this across the PCT.

Some PCTs have simply defined whole parishes as either rural or not. This is not specific enough, as it is possible for one part of a parish to be non-rural and the surrounding countryside to be rural - as in most market towns.

Similarly, just labelling areas as 'unassessed' is no longer possible. As part of the PNA all areas must be defined. If a practice dispensed to patients in an area before April 1983, and that area has not been reassessed since, then it is deemed a controlled area and rural in nature.

The pharmaceutical services entry procedures are open to interpretation in places, and the lack of a clear definition of what makes an area rural is one of them.

Dr Jeremy Phipps: concerns about dispensing boundaries in relation to rural areas

Defining rurality
However, guidelines exist to help decide if an area is rural in character. The guidelines include population density, types of employment, access to transport and services, planning applications pending and the local council's designation.

PCTs making a 'determination of an area' should seek opinions from the LMC, the local pharmaceutical committee, local council and any pharmacy or dispensing practice that may be affected.

The regulations state that as part of the process, there must also be a site visit by the PCT.

When the PCT has made its decision, pharmacies and dispensing doctors have the right to appeal. Assuming the appeal fails, the PCT's decision will stand for five years unless there is a 'substantial change' in the area's circumstances.

For this too there is no definition and only examples of what could count as substantial change are provided. You may think this level of change only occurs when there is new building development in the area, but the converse can also be the case, such as the closure of a major industrial complex.

Check locality
When PNAs are produced, dispensing practices should check their locality carefully to ensure they agree with the rural areas stated. If an area is not designated as rural, doctors cannot dispense to residents even if the nearest pharmacy is more than 1.6km away. If the practice disagrees with the PNA, it should contact the PCT to clarify and, if necessary, to appeal any decision, possibly with the support of the LMC.

Areas that may not appear important can change. For example, pharmacies may move to a new site allowing dispensing by practices to commence. Or a housing development may go ahead. Think how frustrating it would be to discover that you cannot dispense to that new development's residents, even though it was built in an agricultural area on the edge of town, because the practice did not challenge the area's designation as non-rural as no-one was living there.

Practice area
Practices can only dispense with their PCT's agreement (in future, presumably with the NHS Commissioning Board's agreement).

Before 1983, practices could dispense to any patient living more than one mile from a pharmacy (recently updated to 1.6km). Since 1983, the area must be agreed with the PCT and is open to challenges.

If a practice wants to start dispensing or wishes to change its practice area, it should notify the PCT as dispensing is restricted to controlled areas.

The same process may also be necessary where there are practice mergers and takeovers. Simply because an area is rural and the patient lives more than 1.6km from the nearest pharmacy, does not mean that practices can dispense without prior agreement with the PCT.

No one yet knows hows GP dispensing in England will be affected if the proposed abolition of practice boundaries goes ahead. As matters now stand, if a patient living in a rural area wishes to register with a different dispensing practice elsewhere, it is possible that the new practice will not be able to dispense medicines to them. This will be the case even if the patient currently receives medicines from a dispensing practice and even if both dispensing practices are in the same PCT.

If the patient's new practice has not previously applied to the PCT to seek agreement to dispense to the area where the patient is resident, it cannot dispense to the patient.

This is anomalous given that if the patient is a temporary resident with the practice rather than fully registered, then the practice could dispense.

For dispensing practices, checking up each year on the areas of rurality in their locality is essential. If they do not do this, they may find their dispensing list size has fallen.

  • Dr Phipps is a GP at a dispensing practice in Lincolnshire

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