The Implementation and Impact of Healthy Living Pharmacies within the Heart of Birmingham

145 Pages·2014·1.47 MB·English

An Evaluation: The
Implementation and Impact of
Healthy Living Pharmacies within
the Heart of Birmingham

Professor Christopher A Langley
Dr Joseph Bush
Alpa Patel

March 2014
Aston University HLP Study

Published by

Aston Pharmacy School
Aston University
Birmingham
B4 7ET
ENGLAND

www.aston.ac.uk/pharmacy

ISBN 978 185449 462 7
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Table of Contents
ACKNOWLEDGEMENTS ......................................................................................................................................... 6
FOREWORD .......................................................................................................................................................... 8
EXECUTIVE SUMMARY .......................................................................................................................................... 9
GLOSSARY ........................................................................................................................................................... 12
BIOGRAPHIES OF AUTHORS ................................................................................................................................. 13
CHAPTER 1 INTRODUCTION .......................................................................................................................... 14
1.1 THE HEALTHY LIVING PHARMACY CONCEPT........................................................................................ 14
1.2 POPULATION CHARACTERISTICS OF HEART OF BIRMINGHAM TEACHING PRIMARY CARE TRUST ...... 15
1.3 HEALTHY LIVING PHARMACIES IN HOBTPCT ........................................................................................ 15
1.4 EARLY EVIDENCE OF THE IMPACT OF HEALTHY LIVING PHARMACIES ................................................. 18
1.5 THE SERVICES PROVIDED BY HOBTPCT HLPS EVALUATED IN THIS REPORT ........................................... 18
1.5.1 Early Pregnancy Testing .................................................................................................................. 18
1.5.2 Emergency Hormonal Contraception .............................................................................................. 19
1.5.3 Minor Ailments Scheme .................................................................................................................. 20
1.5.4 Smoking Cessation .......................................................................................................................... 22
1.6 CHAPTER SUMMARY ........................................................................................................................... 22
1.7 HLP STUDY AIM AND OBJECTIVES ........................................................................................................ 23
1.8 ETHICAL APPROVALS ........................................................................................................................... 23
1.8.1 NHS ethical approval ...................................................................................................................... 23
1.8.2 Aston University ethical approval ................................................................................................... 23
1.8.3 The cluster’s information governance protocols ............................................................................. 23
1.9 STRUCTURE OF THE REPORT ................................................................................................................ 24
CHAPTER 2 STAGE A – AN ANALYSIS OF SERVICE ACTIVITY DATA ................................................................... 25
2.1 METHODOLOGY .................................................................................................................................. 25
2.1.1 Data collection periods ................................................................................................................... 25
2.1.2 Methodology for EHC and EPT data extraction .............................................................................. 25
2.1.3 Methodology for SC and MAS data extraction ............................................................................... 26
2.1.4 Data Analysis .................................................................................................................................. 26
2.2 RESULTS ............................................................................................................................................... 27
2.2.1 Smoking Cessation analysis/results ................................................................................................ 27
2.2.2 Minor Ailments Scheme analysis/results ........................................................................................ 30
2.2.3 Emergency Hormonal Contraception analysis/results .................................................................... 39
2.2.4 Early Pregnancy Testing analysis/results ........................................................................................ 41
CHAPTER 3 STAGE B – INTERVIEWS WITH SERVICE DELIVERERS ..................................................................... 43
3.1 METHODOLOGY .................................................................................................................................. 43
3.1.1 HLP pharmacist and staff interviews methodology ........................................................................ 43
3.1.2 Qualitative data analysis methodology .......................................................................................... 45
3.1.3 Reporting structure ......................................................................................................................... 46
3.1.4 Background information on HLPs ................................................................................................... 46
3.2 RESULTS FROM THE PHARMACIST INTERVIEWS .................................................................................. 46
3.2.1 Awareness of the demographic profile of local communities served by HLPs ................................ 46
3.2.2 Perceptions of the main objectives an HLP ..................................................................................... 48
3.2.3 Methods implemented by the PCT to disseminate information on the HLP programme ............... 48
3.2.4 Views on the mode and content of the information disseminated on the HLP programme ........... 49
3.2.5 Motivation to participate in the HLP programme ........................................................................... 50
3.2.6 Demotivating factors likely to impede development of the HLP concept ....................................... 53
3.2.7 Pharmacists’ experiences of the accreditation ............................................................................... 54
3.2.8 Realised benefits of undertaking HLP accreditation ....................................................................... 63
3.2.9 Perceived differences between HLPs and non-HLPs ........................................................................ 64
3.2.10 Health services ............................................................................................................................ 65
3.2.11 Multi-skilled pharmacy team ...................................................................................................... 67
3.2.12 Barriers to health service delivery: resource constraints ............................................................ 67
3.2.13 Barriers to health service uptake ................................................................................................ 68
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3.2.14 Promotional activities to raise awareness of HLPs ..................................................................... 70
3.2.15 HLP-led promotional activities .................................................................................................... 72
3.2.16 The extended role pharmacists as healthcare providers ............................................................ 74
3.2.17 Going forward ............................................................................................................................ 78
3.2.18 Pharmacists’ recommendations ................................................................................................. 81
3.3 RESULTS FROM THE HT/HTC INTERVIEWS ........................................................................................... 83
3.3.1 Background information on HT/HTC qualifications ........................................................................ 83
3.3.2 Awareness of the demographic profile of local communities served by HLPs ................................ 83
3.3.3 Perceptions of the main objective of an HLP .................................................................................. 84
3.3.4 Difference between HLPs and non-HLPs ......................................................................................... 85
3.3.5 Method of HT/HTC recruitment ...................................................................................................... 86
3.3.6 Reason for undertaking HT/HTC training ........................................................................................ 86
3.3.7 Comparison between the pharmaceutical–related role and HT/HTC qualification undertaken ..... 87
3.3.8 Training resources ........................................................................................................................... 87
3.3.9 Similarities in the health-service related responsibilities undertaken by interviewees across HLPs90
3.3.10 Benefit of undertaking the health-service related role ............................................................... 91
3.3.11 Staff support and guidance ........................................................................................................ 91
3.3.12 Feeling valued by the pharmacist ............................................................................................... 93
3.3.13 Health service advice/delivery process ....................................................................................... 93
3.3.14 Multi-skilled workforce facilitated provision of health services on a walk-in basis .................... 94
3.3.15 Challenges to service delivery ..................................................................................................... 95
3.3.16 Facilitators to health service uptake .......................................................................................... 98
3.3.17 Patients’ understanding of ‘HLP’ and ‘HT’ terminology ............................................................. 99
3.3.18 Level of local awareness of the HLP concept and health services provided ............................... 99
3.3.19 Promotional activities undertaken to raise awareness of the HLP concept ............................. 100
3.3.20 Promotional activities undertaken to raise awareness of the health services offered by HLPS 101
3.3.21 Prompts which instigated proactive promotion of health services .......................................... 101
3.3.22 Value placed on the health services provided by HLPs ............................................................. 102
3.3.23 Recommendations .................................................................................................................... 103
CHAPTER 4 STAGE C – THE VIEWS OF THE SERVICE USERS ........................................................................... 105
4.1 METHODOLOGY ................................................................................................................................ 105
4.2 RESULTS ............................................................................................................................................. 106
4.2.1 Number of returns ........................................................................................................................ 106
4.2.2 NHS Health service – current and past access .............................................................................. 106
4.2.3 Pharmacy staff .............................................................................................................................. 108
4.2.4 The health advice .......................................................................................................................... 109
4.2.5 Location of consultation ............................................................................................................... 109
4.2.6 Awareness of Healthy Living Pharmacies ..................................................................................... 111
4.2.7 Demographics of respondents ...................................................................................................... 112
CHAPTER 5 DISCUSSION AND CONCLUSIONS ............................................................................................... 114
5.1 SUMMARY OF PROJECT FINDINGS FROM STAGE A ............................................................................ 114
5.1.1 Smoking cessation ........................................................................................................................ 114
5.1.2 Minor ailments scheme ................................................................................................................. 115
5.1.3 Emergency hormonal contraception ............................................................................................. 116
5.1.4 Early pregnancy testing ................................................................................................................ 116
5.1.5 Limitations of the approach adopted for Stage A ......................................................................... 116
5.2 SUMMARY OF PROJECT FINDINGS FROM STAGE B ............................................................................ 116
5.2.1 Motives for engagement with the HLP programme ..................................................................... 116
5.2.2 Challenges to implementation of the HLP programme ................................................................. 117
5.2.3 Effects of HLP accreditation on pharmacy staff ............................................................................ 117
5.3 SUMMARY OF PROJECT FINDINGS FROM STAGE C ............................................................................ 120
5.3.1 Key findings ................................................................................................................................... 120
5.3.2 Limitations .................................................................................................................................... 121
5.4 CONCLUSIONS AND RECOMMENDATIONS ....................................................................................... 121
5.4.1 Conclusions ................................................................................................................................... 121
5.4.2 Recommendations ........................................................................................................................ 123
REFERENCES ...................................................................................................................................................... 125
APPENDICES ...................................................................................................................................................... 128
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APPENDIX 1 - HLP PHARMACIST STRUCTURED INTERVIEW SCHEDULE ............................................................................ 128
APPENDIX 2 – HT/HTC STRUCTURED INTERVIEW SCHEDULE ....................................................................................... 132
APPENDIX 3 – LETTERS OF INVITATION..................................................................................................................... 136
APPENDIX 4 – PARTICIPANT INFORMATION SHEET AND CONSENT FORM ......................................................................... 138
APPENDIX 5 – SERVICE USER QUESTIONNAIRE .......................................................................................................... 141
APPENDIX 6 – COPY OF SERVICE POSTER .................................................................................................................. 145

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ACKNOWLEDGEMENTS
The research team would like to take this opportunity to thank a myriad of people who have all
contributed towards the successful completion of this study.
Study Participants
We would like to express our sincere thanks to all HLP pharmacists, Health Trainer Champions and
Health Trainers, who generously gave their time to undertake an interview and share their
experiences, views, and opinions with the research team. Due to the anonymous nature of the
content in this report, we are unable to name these individuals. However, we are grateful for each
individual’s contribution, which collectively, has informed our understanding of the multitude of
factors that have spearheaded change and influenced the shaping of service provision in the ten
HLPs included in this study.
Data providers
To the individuals listed below, our special thanks for undertaking the onerous task of data collation
and obligingly accommodating our numerous data extraction requests:
• Sharon Bristoll, Birmingham and Solihull NHS Cluster.
• Musa Dhalla, Webstar Health.
• Heather Frazer, Birmingham Public Health.
• Ajay Kumar Polsani, Webstar Health.
Information Governance
We extend our thanks to the Cluster’s Information Governance team, Alison Baylis and Alan
Haycock, whose guidance and support was invaluable in the development of protocols to safeguard
data security and confidentiality.
IT support
Our heartfelt thanks to staff at Health Exchange who were pivotal in enabling deployment of the
electronic service-user questionnaire via touchscreen health kiosks, located in all ten HLPs.
Therefore, the research team would like to acknowledge their sincere gratitude to:
• Patrick McCormick, who supported us with our endeavour and facilitated access to key
members of staff with the relevant expertise;
• Aaron Twitchen, whose expertise and effort enabled the successful deployment of the
service-user questionnaires via the kiosks, and
• Phil Jones, who assiduously resolved IT issues related to the kiosk, as and when they arose.
To Craig Everitt, Aston University (IT team), we are grateful for uploading the service-user
questionnaire files onto an Aston University server and helping ensure that the on-line questionnaire
deployed correctly.
Development of the poster for the service-user questionnaire
We would also like to express our thanks to Amos Mallard (Birmingham and Solihull NHS Cluster) for
his creative input and production of the artwork for the questionnaire poster.
Steering Group
Finally, we would like to thank all members of the Steering Group. In particular, we acknowledge the
significant contributions made by both John Morrison and Sajj Raja, who were both unwavering in
their support and whose guidance was essential in helping to shape various aspects of the study and
in facilitating access to the required datasets. Unfortunately, during the latter part of the study, the
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disbanding of the Cluster resulted in the departure of John and Sajj to other NHS organisations.
Although both John and Sajj continued to input to the Steering Group, the role of Chair of the HLP
study Steering Group was subsequently taken-up by John Nicholls, and we offer our deepest thanks
to John for being steadfast in his commitment to fulfil this, for which we are grateful.
We would also like to express our sincere thanks to Dipak Shah and Zahid Chishti both of whom
kindly agreed to review the draft reports and provided valuable input to the final report.
This study was funded by the Pharmaceutical Trust for Educational and Charitable Objects (PTECO)
(which was subsequently merged with the Pharmacy Practice Research Trust (PPRT) to become
Pharmacy Research UK).
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FOREWORD
“Community pharmacies are a valuable and trusted public health resource. With millions of contacts
with the public each day, there is real potential to use community pharmacy teams more effectively
to improve health and wellbeing and reduce health inequalities.”
Department of Health (2010) Healthy Lives, Healthy People: Our strategy for Public Health in England [white paper]
London: Stationery Office (Cm 7985)
“Pharmacies will become healthy living centres: promoting and supporting healthy living and health
literacy; offering patients and the public healthy lifestyle advice, support on self-care and a range of
pressing public health concerns; treating minor ailments and; supporting patients with long-term
conditions.”
Department of Health (2008) Pharmacy in England: Building on strengths, delivering the future [white paper] London:
Stationery Office (Cm 7341)
The development of community pharmacies, as healthy living centres, has the potential to make a
significant impact on optimising health gains and reducing health inequalities.
For many years pharmacies across the country have provided public health interventions at a local
level, such as smoking cessation or sexual health services. Until now these services have mostly been
delivered in isolation based on local needs and the relationships between local contractors and
commissioners. The Healthy Living Pharmacy concept has the potential to pull these services
together and change the public perception of pharmacy as a simple dispenser of medicines into a
trusted Public Health provider.
John Morrison
Chief Pharmacist, Worcestershire Health and Care Trust
February 2014

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EXECUTIVE SUMMARY
E.1. Community pharmacy’s traditional functions were focussed on the procurement, storage
and compounding of medicines. Over the last three decades, the focus of activity of
community pharmacy has shifted away from these technical aspects towards a patient-
oriented focus on pharmaceutical care and the delivery of health-improving and harm-
reducing services to the public.
E.2. The 2008 pharmacy White Paper ‘Pharmacy in England’, proposed the concept of
pharmacies as ‘healthy living centres’, which would see pharmacies become a primary and
trusted source of advice for healthy living and health improvement within local
communities.
E.3. Since the publication of Pharmacy in England, the healthy living centres concept has been
adopted by the professional leadership body for pharmacy (the Royal Pharmaceutical
Society), numerous pharmacy contractor organisations (e.g. the National Pharmacy
Association, the Company Chemists’ Association) and community pharmacy’s negotiating
body in NHS matters (the Pharmaceutical Services Negotiating Committee), and has been
rebranded as the ‘Healthy Living Pharmacy’ (HLP) concept.
E.4. NHS Portsmouth (at the time, the organisation responsible for the provision of NHS primary
care services to the residents of the city of Portsmouth) assumed some degree of leadership
for the HLP concept by developing a model for HLPs which was launched in December 2009.
The ‘Portsmouth model’ was characterised by an ‘HLP framework’ which formed the basis
for accreditation frameworks across England in areas taking part in a national pathfinder
programme.
E.5. It was as part of this pathfinder programme that Heart of Birmingham teaching Primary Care
Trust (HoBtPCT) began to accredit HLPs within its geographical boundaries. The HLP scheme
in HoBtPCT was launched with a prospectus which was published in March 2011. This
document highlighted the PCT’s commitment to the HLP concept, detailed the PCT’s vision of
an HLP, outlined the PCT’s approach to developing HLPs and invited local community
pharmacies to participate in the programme.
E.6. HoBtPCT provided healthcare services for approximately 300,000 people in the geographical
centre of Birmingham. The area covered by the PCT incorporated Birmingham city centre
and numerous ‘inner-city’ wards including Aston, Ladywood, Nechells and Sparkbrook.
HoBtPCT planned and developed services with in excess of 170 General Practitioners (GPs)
operating from approximately 75 practice premises.
E.7. The community pharmacies of central Birmingham are located in some of the most deprived
areas of England. Their location affords an opportunity to meet the health needs of those
most in need of access to healthcare services but who find it most difficult to access such
services.
E.8. This report details the findings from a review of the implementation of HLPs within HoBtPCT.
Data on service provision for four healthcare services (early pregnancy testing, emergency
hormonal contraception, minor ailments scheme, and smoking cessation) were analysed,
along with data from a series of interviews with service providers and from a service-user
questionnaire deployed via touchscreen kiosks located within the ten HLPs included in this
study.
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E.9. Data on service provision presented in this report suggest that people accessing the services
provided by the community pharmacies in central Birmingham are, unsurprisingly given their
geographical location, predominantly from areas of high socioeconomic deprivation.
E.10. Analysis of the data from the smoking cessation scheme suggests that participants at HLPs
are more likely to have been from sections of society commonly considered to be ‘hard-to-
reach’ – men, people from black and minority ethnic groups, those who had never worked or
were long-term unemployed and those from the most-deprived areas of central
Birmingham. While this phenomenon was not observed universally across all four services
analysed, smoking is the most important single behavioural cause of health inequalities
making such observations notable.
E.11. Of particular note in relation to the analysis of the data from the minor ailments scheme was
the large quantity of medicinal products which were supplied via the scheme but which are
not supported by robust evidence to support their efficacy. Any continuation or extension of
the minor ailments scheme should be accompanied by a review of the items which are
available for supply so as to minimise any expenditure on potentially ineffective
interventions.
E.12. This evaluation has revealed no evidence that HLP accreditation improves activity levels or
outcomes in the services examined (early pregnancy testing, emergency hormonal
contraception, minor ailments scheme, and smoking cessation). However, data from the
minor ailments scheme suggests that HLP accreditation may influence how participants
become aware of the services offered by pharmacy.
E.13. Results from the service-user questionnaire suggest that satisfaction with the services
provided by HLPs is very high. Particularly notable are the high proportions of respondents
who reported that they preferred to access the service they had used at the HLP rather than
at their GP surgery.
E.14. Qualitative data suggest that a motive for contractor engagement with the HLP programme
was a belief that accreditation of their pharmacies as HLPs would provide reassurance to
commissioners that they were consistent deliverers of high quality services and that the
accreditation would help to differentiate HLPs from non-HLPs with HLPs being favoured in
future commissioning decisions. The NHS landscape has changed markedly since the data
were collected and given such change, additional effort will need to be made if the initial
momentum behind HLPs in central Birmingham is not to be lost.
E.15. The concern expressed by pharmacy contractors around remuneration for additional
services should be noted. There was a belief that remuneration for such services was
insufficient to divert activity away from the dispensing function towards patient-centred
care. Whilst such considerations may be outside the scope of local pharmacy and health
bodies, strategic level consideration should be given to how remuneration for pharmacies
can be altered to support role extension and the HLP concept.
E.16. Of additional note were the observations by non-pharmacist staff (Health Trainers and
Health Trainer Champions – HT/HTCs) that the depth of training in relation to the delivery of
certain services was insufficient and that the awareness levels of the HLP scheme by general
practitioners were low. Any development of the HLP model will need to ensure adequate
training levels for pharmacy staff and an increase in the level of awareness within the local
general practitioner population of the programme.

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