Community Pharmacy Domiciliary Smoking Cessation

Local Commissioned Service: Community Pharmacy Domiciliary Smoking Cessation 1. Background Brighton & Hove City Council is commissioning a high qua...
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Local Commissioned Service: Community Pharmacy Domiciliary Smoking Cessation

1.

Background

Brighton & Hove City Council is commissioning a high quality, evidence-based domiciliary smoking cessation (DSC) service. The objective of the service is to provide free smoking cessation support to housebound patients with chronic obstructive pulmonary disease (COPD) and other long term conditions.

2.

Local Context

In Brighton & Hove respiratory diseases are the third main cause of death after circulatory diseases and cancer (274 deaths in 2013, 13% of all deaths). 1 COPD and pneumonia are the most common causes of respiratory disease deaths. In 2013/14, there were 3,737 people recorded as having COPD on Brighton & Hove GP registers. 2 COPD is the second most common cause of emergency admission to hospital and one of the most costly diseases in terms of acute hospital care in England.3 There were 474 emergency admissions for COPD in Brighton & Hove in 2012/13.4 Three of the highest emergency admission rates for GP practices in Brighton are from practices in the more deprived areas.5 Mortality from COPD reflects social inequalities, with men aged 20–65 years in unskilled manual occupations being 14 times more likely to die from COPD than those in professional occupations.6 The smoking prevalence from the Integrated Household Survey shows that smoking prevalence in Brighton & Hove is 25.2%, which is higher than the prevalence for England (18.4%).7 It has been estimated that 80% of COPD-related deaths can be attributed to smoking.8 Quitting smoking when COPD is already developed cannot reverse the disease but can help to slow its progress.9 10 11 Smoking cessation is more effective than all known pharmacological treatments for COPD and can also reduce the severity of COPD symptoms.12 13 The most effective way to quit smoking is by using a combination of 1 Office of National Statistics. Vital Statistics Tables (VS3). 2013. 2 www.qof.hscic.gov.uk 3 South East Public Health Observatory. Inequalities in primary care: what can analysis of QOF data reveal? Summary report for Brighton and Hove PCT. July 2011 4 http://www.erpho.org.uk/inhale.aspx 5 Emergency admissions for COPD – MSOA based estimates 2003/04 to 2007/08 6 London Health Observatory: Respiratory Disease. Available http://www.lho.org.uk/LHO_Topics/National_Lead_Areas/NationalSmoking.aspx [Accessed 15.09.15] 7 The Local Tobacco Control Profiles for England toolkit http://www.tobaccoprofiles.info/ 8 US Department of Health and Human Service. (2014). The Health Consequences of smoking-50 years of progress: A report of the Surgeon General. 9 44 Willemse BW, Postma DS, Timens W, ten Hacken NH. The impact of smoking cessation on respiratory symptoms, lung function, airway hyper responsiveness and inflammation. Eur Respir J 2004; 23:464. 10 45 Scanlon PD., Connett LA., Waller MD. Et al (2000). Smoking cessation and lung function in mild to- moderate chronic obstructive pulmonary disease. The Lung Health Study. American Journal ofRespir Crit Care Med, 161, 381-290. 11 British Lung Foundation website, COPD. Accessed 11 January 2011 12 Kanner RE, Connett JE, Williams DE, Buist AS. Effects of randomized assignment to a smoking cessation intervention and changes in smoking habits on respiratory symptoms in smokers with early chronic obstructive pulmonary disease: the Lung Health Study. Am J Med 1999; 106:410.

behavioural therapy and pharmacotherapy.14 Recent evidence suggests that when using medication and counselling, people with COPD can achieve quit rates comparable to those observed in the general population.15 Earlier evidence indicates that over 80% of COPD patients aged 60 and over are housebound due to their condition. 16 17 Therefore accessing smoking cessation services (SCS) in the community could be problematic for these patients and may impact on their ability to quit smoking as advised by their healthcare professional.

3.

Pharmacy Smoking Cessation Service

Within Brighton & Hove the community smoking cessation service operates across 76% (48/63) of pharmacies and 78% local GP practices (35/45) (see map). In 2014/2015, 28% (404/1,423) of all successful quits were achieved collectively by the pharmacy SCS. Over the course of the same period the pharmacy SCS achieved an 81% quit rate, which exceeded the City’s quit ratio of 65% and was reflective of exceptional performance.18 This means that for every five patients accessing SCS delivered by pharmacies only one will continue to smoke. The City’s pharmacy SCS is reflective of an equitable service, delivered to a high standard and has exceeded performance outcomes for smoking cessation.

13 Godtfredsen NS, Lam TH, Hansel TT Leon ME. COPD-related morbidity and mortality after smoking cessation: status of the evidence. European Respiratory Journal. 2008. 32: 844–853 DOI: 10.1183/09031936.00160007 14 49 Wagena EJ, van der Meer RM, Ostelo RJ et al. (2004). The efficacy of smoking cessation strategies in people with chronic obstructive pulmonary disease: results from a systematic review. Respir Med, 98(9), 805-815. 15 Tashkin DP, Rennard S, Hayes JT et al. (2011). Effects of Varenicline on patients with mild to moderate COPD: a randomised controlled trial. Chest, 139(3), 591-599 16 Gore JM, Brophy CJ, Greenstone MA (2000) How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax 55: 1000-1006. 17 Rao, J.K., Anderson, L.A., Smith, S.M. End of life is a public health issue. Am J Prev Med. 2002;23:215–220. 18 National Institute for Health and Care Excellence (2013). Smoking Cessation Services, (PH10). NICE: http://publications.nice.org.uk/smoking-cessation-services-ph10

4.

5.

Aims of the Domiciliary Service 

The DSC service builds upon the existing best practice and service delivery model adopted by the pharmacies, utilising the effective and highly skilled stop smoking workforce to delivering a home-based SCS for patients with COPD and other long term conditions.



The DSC service will provide one to one behaviour support along with stop smoking medicines to patients within their own homes.



To improve access to SCS through the development of a citywide domiciliary service that mirrors the population coverage of the six GP clusters to ensure equitable access to home based services (Appendix 1). Twelve pharmacies will be initially selected using the agreed selection criteria (Appendix 2). Six pharmacies will be aligned with each of the 6 GP clusters (one per GP cluster) and the additional pharmacies selected to meet the demands of prevalent locations. The prevalent location in Brighton and Hove is defined as the East Locality.

Service Outline

The DSC service shall be delivered in line with the most recent evidence based practice recommendations for smoking cessation services issued by the National Institute for Health and Care Excellence (NICE) and Local Smoking Cessation Services: Service and delivery guidance 2014 published by Public Health England (PHE). The service delivery model is outlined within the Pharmacy LCS specification, incorporating the four stages of service delivery in accordance to The Shropshire Help 2 Quit Model 19 and monitored to The Russell Standard. 20 Stage 1

Initial assessment*

Stage 2

Quit Day*(set by the patient)

Stage 3

Support following Quit Day (usually by phone, but can be a visit as part of the DSC specification)

Stage 4

Four week Quit follow up appointment i.e. 4 weeks after Quit Day* Supply 4 weeks of NRT and inform the patient to phone the pharmacy to arrange an additional 4 week supply of NRT if required.

Stage 5

Supply and deliver to the patient the remaining 4 weeks of NRT. *A face to face consultation is required.

19 Kevin Lewis (1995) Shropshire County and Telford and Wrekin PCTs Help 2 Quit service 20West, R. (2005) Assessing smoking cessation performance in NHS Stop Smoking Services: The Russell Standard (Clinical). Available from: http://www.ncsct.co.uk/publication_The-Russell-Standard.php

6.

Referral Pathways

Patients in hospital will receive an initial stop smoking assessment by the Hospital Smoking Cessation Service Lead (HSCSL). Patients identified to be housebound will be referred to their local DSC service by the HSCSL to receive support within their own home from a local pharmacy provider. Patients in the community identified by the Community Respiratory Service will be referred to the HSCSL, who will be responsible for referring these patients into the DSC service. The referral information for community and hospital patients will be sent using a secure NHS email account to the DSC pharmacy by the HSCSL. The referral criteria will include a patient risk assessment, a partially completed gold standard monitoring form and patient information and consent recorded on the DSC referral form (Appendix 3). If a risk assessment is not available from the hospital or community services, then pharmacies can complete their own risk assessment (Appendix 4). The pharmacy will be accountable for implementing the risk assessment and any associated measures after completion. Patients referred from GP surgeries, pharmacies (not offering the DSC service) and other health or social care services must have a DSC referral form completed and information must be transferred using a secure NHS email account that meets the requirements of the Data Protection Act. The DSC pharmacies will be accountable for implementing the risk assessment and any associated measures after completion. Pharmacies providing the DSC service can initiate housebound patients however a DSC referral form must still be completed to comply with service auditing requirements. The DSC pharmacies will be accountable for implementing the risk assessment and any associated measures after completion. See Appendix 5 for referral pathway information.

7.

Pricing

Smoking cessation service The payment and claim procedure for the delivery of the SCS aspect of the domiciliary service would be governed by the Pharmacy LCS SCS specification. Domiciliary Service The payment allocated to fund the domiciliary aspect of the SCS has been agreed with the LPC at £25 per visit. The visit cost takes into account initial set up (domiciliary training, enhanced DBS checks, risk assessment and lone working policies) and delivery costs for visits (staff wages, travel, parking, insurance and mobile phone costs). A maximum of four visits can be claimed per patient as outlined in section 5. To undertake the domiciliary service the smoking cessation advisor will need to access to a NRT home visit kit bag. For guidance on the type of contents to be included within the kit bag please see Appendix 6.

8.

Record keeping 

The pharmacy must maintain appropriate records for SCS delivered under the domiciliary service as defined in Appendix 7 

Number of housebound patients accessing the domiciliary service.



Number of home visits undertaken by the smoking cessation advisor (SCA).



Number of Quit Day set, phone calls or visit made as a follow ups and four week quits achieved.



SCS data as outlined within the LCS SCS specification.



Submission of the Gold Standard Monitoring Form (titled domiciliary SCS) within 2 weeks of the quit date to the Smoking Cessation Lead at Royal Sussex County Hospital.



The SCA must give or send a patient satisfaction questionnaire (Service User Survey (Appendix 8) to all domiciliary service users setting a quit date within 2 weeks of the 4 week quit follow-up appointment.

9.

Responsibilities of the Pharmacy 

A lone working and risk assessment polices must be in place to safeguard and protect staff members delivering the domiciliary service.



Ensure SCAs are fully enabled to raise safeguarding issues with their line manager, and where appropriate support these members of staff to raise safeguarding concerns with the local authority.



Ensure that all SCAs delivering the domiciliary service have completed a successful enhanced DBS checked.



Pharmacies must have in place adequate business insurance to deliver the SCS as a domiciliary service.



The pharmacy must submit appropriate data on time for domiciliary payment and in line with the Pharmacy LCS specification claim process including gold monitoring forms and patient satisfaction questionnaires within the required timescales.



Comply with the auditing procedures for locally commissioned services as defined in the service contract.

10.

Eligibility and Accreditation



Pharmacies signing up to and delivering the Pharmacies Local Commissioned Smoking Cessation service are eligible to apply to become a domiciliary provider.



All SCAs delivering the service must successfully complete the Brighton and Hove NHS Centre for Stop Smoking Training level 2 and undertake continuing professional development by attending update stop smoking training.



Domiciliary SCAs are required to attend a 1 day Domiciliary Smoking Cessation specific training course. This training will cover such areas of work as: 

Safeguarding, lone working and managing risk



COPD and the benefits associated with giving up smoking



Best practice in delivering a home based smoking cessation service



Behaviour change and motivational interviewing for patients with long term health conditions



DSC service specification and process.



Pharmacies must adhere to the Data Protection Act by utilising a NHS email account for communication with hospital and community services and for the data sharing of patients’ information.



By meeting the service eligibility criteria the pharmacy has been judged to be “a qualified provider”.



Pharmacies must submit a Declaration of Competences (Appendix 9) for each SCA providing the DSC service to the service commissioner before the service start date.



Patients referred to the DSC service must be Brighton and Hove residents.

11.

Termination and Change Arrangements

The local commissioned service is for the period 1st January 2016 to 31st March 2017 with a six month review in June 2016 and an end of year audit in March 2017. Termination can be made earlier by either party at 3 months’ written notice or on failure to provide activity data as stated in section 8.

Document Title: LCS for Domiciliary Smoking Cessation Service Prepared by: Greg Cooper, Public Health Directorate Contact Details: Tel: 01273 296556 / E: [email protected] Version Number: Version 1 - 1/12/2015 For Distribution to: Domiciliary Pharmacy Providers Issue Date: 18th January 2016 Review Date: 1st June 2015 End Date: 31st March 2017

Appendix 1

GP Cluster 1 No. on Map 1 2 3 4 5 6

Practice name Albion Street Ardingly Court Surgery Park Crescent Pavilion Surgery St Peter’s Medical Centre Brighton Homeless Health Centre TOTAL

GP Cluster 4 Responsible Population 6125 6230 13244 8913 11219 1138 46869

No. on Map 1 2 3 4 5 6 7

Practice name Benfield Valley Healthcare Hub The Practice Hangleton Manor Hove Medical Centre Links Road Surgery Mile Oak Medical Centre Portslade Health Centre Wish Park Surgery TOTAL

Responsible Population 5575 2010 8730 5818 7641 12186 5894 47854

GP Cluster 2 No. on Map 1 2 3 4 5 6 7 8 9

Practice name Avenue Surgery Broadway Surgery Ridgeway Surgery Saltdean & Rottingdean Medical Practice School House Surgery Ship Street Surgery St Lukes Surgery Willow House Surgery Whitehawk Surgery TOTAL

Responsible Population 6772 2346 2334 9564 4407 2068 2296 1959 3339 35085

Practice name Beaconsfield Surgery Preston Park Surgery Stanford Medical Centre Warmdene Surgery TOTAL

No. on Map 1 2 3 4 5 6

Responsible Population 10196 11101 16226 9174 46697

Practice name Boots North Street Brighton Station Health Centre Carden Surgery Seven Dials Medical Centre Haven Practice University of Sussex TOTAL

Responsible Population 2082 5767 5731 7848 3067 16925 44120

GP Cluster 6 No. on Map 1

GP Cluster 3 No. on Map 1 2 3 4

GP Cluster 5

2 3 4 5 6

Practice name Brighton Health and Wellbeing Centre Central Hove Surgery Charter Medical Centre Goodwood Court Medical Centre Hove Park Villas Surgery Sackville Road Surgery TOTAL

Responsible Population 8188 5458 17923 9747 4473 11289 57078

Appendix 2

Selection Criteria for the Domiciliary Smoking Cessation (DSC) Service in Community Pharmacy To help with the selection process one point will be allocated for each of the criteria met. No:

Criteria

1.

The pharmacy is already providing a SC service as of 1/10/15 and the smoking cessation advisor (SCA)has completed the B&H accredited course

2.

The SCA is able to attend a one day training course on the11th November at a B&H venue

3.

The pharmacy is able to set up an NHS email account to allow the secure transfer of information.

4.

The pharmacy is in the top 25% of pharmacies achieving 4 week quits based on the last 2 quarters data.(this information will be added by public health)

5.

The quit rate is above 65% i.e. 65% of people initiated into the service go on to achieve a 4 week quit.

6.

The pharmacy is in a prevalent location( i.e. the prevalent area for smoking is East Brighton)

7.

The pharmacy has achieved Healthy Living Pharmacy accreditation.

8.

The pharmacy is able to provide an equitable service as defined by the service specification. Please list in the notes sections three actions the pharmacy will take to promote the service to patients and other healthcare providers.

Points

Notes

1.

2. 9.

3.

Total Points Please Note: Criteria 1, 2 &3 are essential criteria for selection. Pharmacy Name

Pharmacy Address Email address

Appendix 2

Appendix 2 Domiciliary Smoking Cessation Pharmacies for Brighton & Hove PHARMACY NAME

ADDRESS 1

ADDRESS 2

POSTCODE

TEL.NO

Coldean Pharmacy

16 Beatty Ave

Coldean

BN1 9ED

01273 605657

Boots

129 North Street

Brighton

BN1 2BE

01273 207461

Gunns Pharmacy

108 Western Rd

Brighton

Bn1 2AA

01273 734227

O'Flinns Pharmacy

77-78 Islingword Rd

Brighton

BN2 9SL

01273 681630

Harpers Pharmacy

12 Hollingbury PL

Brighton

Bn1 7GE

01273 505817

Fields Pharmacy

38-40 Eldred Ave

Brighton

Bn1 5EG

01273 502447

Lane and Steadman

100 Western Rd

Hove

BN3 1GA

01273 734919

Charter Pharmacy

88 Davigdor Rd

Hove

BN3 1RF

01273 208233

Kamsons Pharmacy

50 The Highway

Brighton

BN2 4GB

01273 686853

Appendix 3

Appendix 4

Appendix 5

Hospital Referral Referral from the Integrated Respiratory Service

Initial Assessment with Hospital Smoking Cessation Service Lead (HSCSL) Anna Fairhurst [email protected]

HSCSL completes Hospital DSC Referral Form and refers housebound patients to their nearest pharmacy offering DSC. The referral form will be sent using a NHS secure email account.

Pharmacy confirms receipt of referral form and confirms to HSCSL they are willing to offer DSC service.

Pharmacy contacts patient to confirm they can offer service and arrange initial appointment. A risk assessment is completed by the pharmacy during the initial visit.    

Anna Fairhurst St Mary’s Hall RSCH 01273 696955 Ext. 7445 Bleep 8335

Appendix 5

Community Respiratory Service Referral Referral from the Integrated Respiratory Service. Send the completed Domiciliary Smoking Cessation (DSC) referral form via a NHS email to Anna Fairhurst [email protected] * see below for contact information

Initial Assessment with Hospital Smoking Cessation Service Lead (HSCSL) Anna Fairhurst [email protected]

HSCSL completes Hospital DSC Referral Form and refers housebound patients to their nearest pharmacy offering DSC. The referral form will be sent using a NHS secure email account.

Pharmacy confirms receipt of referral form and confirms to HSCSL they are willing to offer DSC service.

Pharmacy contacts patient to confirm they can offer service and arrange initial appointment. A risk assessment is completed by the pharmacy during the initial visit.   



Anna Fairhurst St Mary’s Hall RSCH 01273 696955 Ext. 7445 Bleep 8335

Appendix 5

GP Referral

The GP surgery will contact the DSC pharmacy using secure a NHS email and provide a completed Community Referral Form. (DSC pharmacies are listed on the back of the referral form)

Pharmacy confirms receipt of information and confirms to the GP surgery they are willing to offer the DSC.

Pharmacy contacts patient to confirm they can offer service and arrange initial appointment. A risk assessment is completed by the pharmacy during the initial visit.

Appendix 5

Social Care or Local Authority Service

The service provider will contact the DSC pharmacy using secure email and provide a completed Community Referral Form. (DSC pharmacies are listed on the back of the referral form)

Pharmacy confirms receipt of information and confirm to the service provider they are willing to offer the DSC.

Pharmacy contacts patient to confirm they can offer service and arrange initial appointment. A risk assessment is completed by the pharmacy during the initial visit.

Appendix 5

Pharmacy (not offering DSC)

The Pharmacy will contact the DSC pharmacy using secure NHS email and provide a completed Community Referral Form. (DSC pharmacies are listed on the back of the referral form)

DSC Pharmacy confirms receipt of information and confirm to the Pharmacy they are willing to offer the DSC.

Pharmacy contacts patient to confirm they can offer service and arrange initial appointment. A risk assessment is completed by the pharmacy during the initial visit.

Appendix 5

DSC Pharmacy Initiating Patients

The Pharmacy will complete a referral form (for auditing purposes) with the housebound person (this can be completed by phone)

Pharmacy contacts patient to confirm they can offer service and arrange initial appointment. A risk assessment is completed by the pharmacy during the initial visit.

Appendix 6

Domiciliary Smoking Cessation Service Kit Bag- recommended contents



Appointment diary and appointment cards



Charged mobile phone and personal alarm



Photo ID



Hand gel



Paperwork file containing, risk assessment forms, initial referral information, consultation record form, emergency contact information, levy declaration form and health promotion leaflets to support behaviour change.



CO monitor and mouth pieces



Nicotine Replacement Therapy- To decide the best option of NRT to take on the visit. Discuss choices with the patient before the visit i.e. gather information about how many cigarettes smoked per day, when they have their first cigarette, have they tried any NRT before and formulation preferences.



If patient pays for prescriptions ensure they are aware that the levy (per formulation) will be collected when the NRT is supplied and ensure change is available.

Appendix 7

Record keeping information 1.

2.

Information required for quarterly payment - enter on quarterly LCS submission form •

Number of housebound people initiated into service



Number of home visits



Number of 4 week quits achieved



NRT supplied



Number of NRT deliveries after 4 week quit. (I.e. NRT can be continued for up to 8 weeks after the 4 week quit date)

Send the Gold Monitoring Form and the Patient Satisfaction Questionnaire to the HSCSL within 2 weeks of the 4 week quit date.

Appendix 8 – Domiciliary Service User Survey We are very keen to improve the service we provide to individuals wanting to stop smoking. Your views about this are very important to us and will be treated in the strictest confidence. Please answer the following questions as honestly as you can. The results of this survey will be used for evaluation and to improve services for the future. Please tick your answer for each question Overall how satisfied are you with the 1 stop smoking service you received at home? Would you recommend this service to 2 another COPD patient?

Unsatisfied

Unsure

Satisfied

No

Unsure

Yes

If you started smoking again would you return to the service for help to stop?

No

Unsure

Yes

3

Was it easy to contact the pharmacy domiciliary stop smoking service?

No

Unsure

Yes

4

How satisfied were you with the amount of time you had to wait for your first appointment with the Domiciliary Service? How helpful was the advisor support?

Too long please specify

Unsure

Satisfied please specify

Unhelpful

Unsure

Helpful

How helpful was the information and advice from the advisor?

Unhelpful

Unsure

Helpful

7

How helpful were the leaflets and resources you received?

Unhelpful

Unsure

Helpful

8

Was it helpful having your carbon monoxide (CO) reading done?

No

Unsure

Yes

9

Were you medication?

No

Unsure

Yes

10

No

Unsure

Yes

5

6

offered

a

choice

of

Was it easy to obtain your medication?

11 12

If you have any suggestions as to how we can improve our Stop Smoking Service please give details here:

Thank you for your time in completing this survey. Please return it to your smoking cessation advisor or in the envelope provided.

Appendix 9

Declaration of Competence Locally Commissioned Domiciliary Smoking Cessation (DSC) Service in Community Pharmacy 1. The Declaration of Competence (DOC) system has been given national support after a series of pilots in England. The purpose of the DOC is to review pharmacists’ and pharmacy employees’ competence to deliver a locally commissioned service and to assure commissioners, they have the appropriate knowledge, skills and behaviours to deliver a high-quality, consistent service. The DOC has been endorsed by NHS England, Health Education England and Public Health England. 2. The training requirements for pharmacy smoking cessation advisors to meet the competencies in the DOC and enable self-certification, to deliver the Domiciliary Smoking Cessation (DSC) Service commissioned service in Brighton and Hove are listed below.

Learning and assessments   

Attend and complete a 2 day intermediate (level 2) Brighton and Hove training course provided by the Hospital Smoking Cessation Service Lead (HSCSL) Attend a full day DSC training workshop Pharmacy Smoking Cessation Advisors must attend 2 out of 3 update training sessions per year provided by the RSCH

3. Complete the pharmacy smoking cessation advisors declaration of competence checklist and return a copy of the following signed documentation to the service commissioner, Greg Cooper, Smoking Cessation Service Commissioner, Public Health, Kings House, Grand Avenue, BN3 2LS or by E-mail to [email protected]

Pharmacy Smoking Cessation advisors Declaration of Competence authorisation checklist for DSC Please read the checklist below, tick the boxes and sign to confirm your competence.

I have attended and completed a 2 day intermediate (level 2) Brighton and Hove training course provided by the Hospital Smoking Cessation Service Lead (HSCSL) I have attended and completed the DSC full day training workshop I agree to attend 2 out of 3 update training sessions per year provided by the HSCSL I have completed a successful enhanced DBS check I have read and understood the service specification for the Domiciliary Smoking Cessation Locally Commissioned Service. My employer has provided a Lone Worker and Risk Assessment Policy for domiciliary visits The Safeguarding contact information in the pharmacy where I work is kept up to date with the relevant contact names and telephone numbers and I feel confident to raise safeguarding issues with my line manager I acknowledge that the service will be audited at least annually and will provide all record keeping information detailed in the service specification within the required timescales

I acknowledge that it is my responsibility to update my knowledge and skills on an ongoing basis and to formally renew my Declaration of Competence for this service every 3 years.

Signed ……………………………………………

Date …………………

Please print name

……………………………………………….

Line Managers Signature

……………………………………………….

Please print name and job title

………………………………………………..

Name and Address of Pharmacy

……………………………………………….. ………………………………………………..

Contact email address

…………………………………………………