Aston HLP Study Presentation of Results 11.03

Today’s Event

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

the Heart of Birmingham

• 13:00 – 13:45 – Arrival and buffet-lunch.• 13:45 – 14:30 – Presentation of the HLP project.• 14:30 – 15:00 – Questions and discussion.

Timings:

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An Evaluation: The Implementation and Impact of Healthy Living Pharmacies within the Heart of BirminghamPharmacy Practice Research Group

School of Pharmacy

Aston University

http://www1.aston.ac.uk/hlp

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Today’s Event

To highlight the findings from the Aston HLP study.

• Introduction to the event.• Introduction to the project.

• What are Healthy Living Pharmacies (HLPs)?• Overview of HoBtPCT’s population and demographics.• Overview of the three stages of the project (including methodology).

• Summary of findings from Stage A of the project.• Summary of findings from Stage B of the project.• Summary of findings from Stage C of the project.• Conclusions.• Overview of recommendations.• Questions and discussions.

Content:

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Introducing the Project Team…

• Professor Chris Langley – Professor of Pharmacy Lawand Practice and a registered pharmacist.

• Dr Joe Bush – Senior Lecturer in Pharmacy Practiceand a registered pharmacist.

• Alpa Patel – Research Projects Coordinator –responsible for the day-to-day management of theproject and the primary point of contact for enquiries.

Aston University Team:

Support from the PCT Steering Group.

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This study was funded by the Pharmaceutical Trust for Educational andCharitable Objects (PTECO) (which was subsequently merged with thePharmacy Practice Research Trust (PPRT) to become Pharmacy ResearchUK).

What are Healthy Living Pharmacies? (1)

Community pharmacy’s traditional functions were located in theprocurement, storage and compounding of medicines.

It was in this context that the 2008 pharmacy White Paper ‘Pharmacy inEngland’, proposed the concept of pharmacies as ‘healthy livingcentres’. This would see pharmacies become a primary and trustedsource of advice for healthy living and health improvement within localcommunities.

Since the publication of Pharmacy in England, the healthy living centresconcept has been rebranded as the ‘Healthy Living Pharmacy’ (HLP)concept.

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Over the last three decades, the focus of activity of community pharmacyhas shifted away from these technical aspects towards a patient-orientedfocus on pharmaceutical care and the delivery of health-improving andharm-reducing services to the public.

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NHS Portsmouth (at the time, the organisation responsible for theprovision of NHS primary care services to the residents of the city ofPortsmouth) assumed some degree of leadership for the HLP conceptby developing a model for HLPs which was launched in December 2009.

The ‘Portsmouth model’ was characterised by an ‘HLP framework’ whichformed the basis for accreditation frameworks across England in areastaking part in the pathfinder programme.

It was as part of this pathfinder programme that Heart of Birminghamteaching Primary Care Trust (HoBtPCT) began to accredit HLPs withinits geographical boundaries.

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Initially, pharmacies within Portsmouth could apply to be accredited asHLPs by NHS Portsmouth if they delivered active health promotioncampaigns, targeted respiratory medicines use reviews (MURs), a stopsmoking service and at least one other service from the ‘Local EnhancedServices’ level of the pharmacy contract.

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Why HoBtPCT?

Birmingham Health and Wellbeing Partnership

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Characteristics of HoBtPCT

HoBtPCT provided healthcare services for approximately 300,000people in the geographical centre of Birmingham.

The population served by HoBtPCT was disproportionately young withalmost a third of the resident population under 19 years of age.

Seventy per cent of people in HoBtPCT were from Black and MinorityEthnic groups – the highest proportion of people from BME groups ofany PCT in England.

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The area covered by the PCT incorporated Birmingham city centre andnumerous ‘inner-city’ wards including Aston, Ladywood, Nechells andSparkbrook. HoBtPCT planned and developed services with in excess of170 General Practitioners (GPs) operating from approximately 75practice premises.

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Project Aim and Objectives (1)

Aim - To evaluate the implementation and impact of HLPs inHoBtPCT.

• To analyse the activity of HLPs using data obtained from compulsory returnsto HoBtPCT from accredited HLPs.

• To compare the activity and services provided from HLPs with the activity andservices provided by those pharmacies within the Primary Care Trust (PCT)not currently involved in the HLP scheme.

• To provide a quantitative estimate of the health gain generated byinvestments in HLPs.

• To elucidate and analyse the views of service providers from the HLPs ontheir;

• motivation for becoming an HLP within HoBtPCT;• experiences at the start of their involvement with the HLP scheme within HoBtPCT;• current experiences of being an HoBtPCT HLP; and,• future plans in relation to the HLP scheme.

Objectives:

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Project Aim and Objectives (2)

Aim - To evaluate the implementation and impact of HLPs inHoBtPCT.

• To explore and evaluate the views of HLP service users.• To make recommendations on the future direction and impact of HLPs within

HoBtPCT.

Objectives (…continued):

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• Stage A – An analysis of service activity data.• Stage B – Interviews with service deliverers.• Stage C – The views of the service users.

Project stages:

Project Stages

• Stage A involved analysis of service activity data forfour services.

Stage A.

• Stage B involved interviews with pharmacy staff from allten of the first round of HLPs within HoBtPCT.

Stage B.

• Stage C involved a service-used questionnairedeployed through touch-screen kiosks.

Stage C.

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Project Overview – Stage A

Compared data from pharmacies before and after HLP accreditation andwith non-HLPs.

• Emergency Hormonal Contraception.• Early Pregnancy Testing.• Smoking Cessation.• Minor Ailments Scheme.

Services under investigation:

Specific data collection methodology varied by service owing to differentpayment arrangements for different services.

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Stage A – Smoking Cessation Data (1)

Between 1st April 2011 and 31st October 2012, 3608consultations occurred in all pharmacies (n=67); 477(13.2%) of which were via HLPs.

• Some seasonal variability in the number ofconsultations was observed.

• No association was observed between the numberof consultations per quarter and HLP status(p=0.062).

Quit status at 4 weeks showed seasonal variation(p<0.001) with a higher proportion of participantssuccessfully quitting in the first two quarters of 2012than in the other quarters for which data were available.

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Quit status at 4 weeks varied based on a number ofdemographic characteristics.• Older participants, male participants and participants from

higher occupational groups all had higher ‘quit’ rates thanyounger participants, female participants and participantsfrom lower occupational groups respectively.

Where quit status at 4 weeks post-enrolment wasrecorded (3598 consultations), 47.6% (n=1712/3598)of participants had successfully stopped smoking.• Quit rates at 4 weeks were slightly higher amongst

participants attending non-HLPs than in participantsattending HLPs although this difference was not statisticallysignificant

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Analysis of the data from the smoking cessationscheme suggests that participants at HLPs are morelikely to have been from sections of societycommonly 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 observeduniversally across all four services analysed,smoking is the most important single behaviouralcause of health inequalities making suchobservations notable.

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Stage A – Minor Ailments Data (1)

Data on service provision were obtained from allpharmacies (n=71) that provided the servicebetween 1st January 2012 and 31st November 2012.• During this timeframe, 194,315 consultations occurred,

23,579 (12.1%) of which were via HLPs (n=10).

There was an association between the mean numberof consultations delivered per month and HLP status(p<0.001).• In all of the eleven months for which data were available, the

mean number of consultations delivered through non-HLPsexceeded the mean number of consultations deliveredthrough HLPs.

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Differences were observed based on IMD quintilewhere 41.7% of consultations delivered via non-HLPs involved a participant from the two mostdeprived quintiles within the cohort compared to28.0% in consultations delivered via HLPs.

Of particular note was the large number of itemswhich were supplied via the scheme but which arenot supported by a robust evidence base.• Any continuation or extension of the minor ailments scheme

should be accompanied by a review of the items which areavailable for supply so as to minimise any expenditure onpotentially ineffective interventions.

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During each consultation, patients were asked if, inthe absence of the MAS, they would have consultedtheir General Practitioner (GP).• Using these data it is possible to provide an estimate of

‘savings’ attributable to patients consulting a pharmacistrather than their GP about their minor ailment(s).

Estimates detailed in the report are based solely onconsultation costs and do not include the costs ofmedicines (for which data were not available).• For these reasons, the most conservative estimate of around

£2,000,000 per annum should be given precedence.

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The numbers of consultations before and afteraccreditation as an HLP were compared:• An increase in the mean number of consultations per month

was observed in the post-accreditation period in 8 of the 10HLPs.

• However, this increase was only statistically significant inthree pharmacies and activity decreased in two HLPs in thepost-accreditation period.

When aggregating the data for all HLPs andcomparing provision in the period August-November2011 with August-November 2012, there was a slightincrease in activity but this increase was notstatistically significant.

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Stage A – Emergency Hormonal Contraception (1)

Data extraction yielded a total of 79 consultations, 61in HLPs and 18 in non-HLPs. A total of 37 of theseconsultations took place in the periods prior toaccreditation of the HLPs and 42 after accreditation.

All participants were from the two most deprivedquintiles of LSOAs in England.

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There was no association between the age of serviceusers and HLP status.

Over half (55.6%; n=10/18) of individuals accessingthe service at non-HLPs were from the mostdeprived IMD quintile compared to only one-in-ten(10%; n=6/60) via HLPs.

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Stage A – Emergency Hormonal Contraception (2)

Unprotected penetrative sexual intercourse was thereason given for the service user accessing EHC in50 of the 79 consultations (63.3%).

The majority (53.2%; n=42/79) of consultationsexamined were conducted in the post-accreditationperiods.

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Accreditation as an HLP did not appear to have anysignificant effect on activity with only one additionalconsultation taking place in the post-accreditationperiods compared to the periods prior toaccreditation

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Stage A – Early Pregnancy Testing

Data were collected for a total of 505 consultations.• A total of 220 (43.6%) of these took place in HLPs and 285

(56.4%) in comparator non-HLPs.• In the pre-accreditation period, there were 262 (51.8%)

consultations and in the post-accreditation period, therewere 242 (47.9%) consultations (one ‘missing’ value).

There was an association between IMD quintile andHLP status:• almost half (47.7%; n=128/270) of individuals accessing the

service at non-HLPs coming from the two most deprivedquintiles within the cohort compared to 30.4% (n=64/210) atHLPs.

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There was no association between the age of serviceusers and HLP status.

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Project Overview – Stage B

Interviews were undertaken with staff from all ten HLPs in the study.

• Lead pharmacist (one interview per pharmacy).• HT or HTC (one interview per pharmacy).

• Health Trainer – an individual who has undertaken the City &Guilds Certificate for Health Trainers at Level 3 qualification.

• Health Trainer Champion – an individual who has undertaken theRSPH Level 2 Award in Understanding Health Improvementqualification.

Participants interviewed:

All interviews were transcribed verbatim and analysed by themes.

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Stage B - Motives

The majority of interviewees reported that they were undaunted by theHLP accreditation criteria as they were already meeting most of theaccreditation criteria prior to engaging in the HLP programme.

• It was believed that HLP accreditation would identify the pharmacy as beingone which could be relied upon, by both patients and NHS commissioners, toprovide consistently high quality services.

• Pharmacists believed that pharmacies with HLP accreditation would come tobe seen as ‘preferred providers’ of future locally commissioned servicestherefore securing their pharmacies a competitive advantage over non-HLPsand helping to ensure the financial sustainability of their businesses in theshort- to medium-term.

The most commonly reported motivation for engagement with the HLPprogramme was that accreditation as an HLP would differentiate thepharmacy from other, competitor pharmacies.

The other prime motive for engagement in the HLP programme was analtruistic desire on the part of pharmacists to improve the health of thecommunities which they serve.

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Stage B – Challenges

• Role extension placing ever greater pressures on pharmacist workloadparticularly in the context of year-on-year increases in the volumes of prescriptionsto be dispensed.

• Remuneration for extended services being insufficient to cover recruitment ofextra staff to accommodate for an increasing workload.

• In the light of the above, precedence being given to the dispensing ofprescriptions amidst fear of regulatory action being taken against the pharmacistin the event of a dispensing error.

• Poor recognition of the HLP brand as a quality kite mark by members of thepublic primarily as a failure of the PCT-led marketing and promotional activities.

• A difficulty in persuading clients of the differences in daily operations before andafter accreditation as the local populations were accustomed to accessing healthservices via pharmacies for several years before the introduction of HLPs.

• Some interviewees did not consider that the HT/HTC training had been of benefitin altering and developing their practice.

• A lack of clarity amongst pharmacists as to the differences in the defined roles ofHTs/HTCs .

A number of challenges were highlighted:

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Stage B – Effect on pharmacy staff

The majority of HTs/HTCs felt a sense of achievement and pride infulfilling a health-service related role and were of the view that patientsvalued and appreciated the advice/health service provided.

• Able to consult pharmacists readily about any issues they had regarding theirworking practice.

• Supported by their employer in their ‘new’ role, a role which had become more‘client-centred’ and this had led to HTs/HTCs feeling ‘valued’ by their employer.

The majority of HTs/HTCs felt:

However, HTs/HTCs reported that peer support was virtually non-existent. There was no communications amongst HTs/HTCs working indifferent pharmacies and there was a belief that peer networking wouldbe valuable in enabling transfer of knowledge and sharing of bestpractice amongst HTs and HTCs to facilitate continued improvement ofservice delivery in HLPs.

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Project Overview – Stage C

Stage C – Views of service users.

In total, 445 service-users completed questionnaires via the touchscreenkiosk (aided, if appropriate, by a member of the pharmacy team).

Of the total number of respondents, 85.8% of questionnaire respondents(n=364/424) indicated that the HLP at which the questionnaire wascompleted was their regular pharmacy, with 14.2% (n=60/424) indicatingthat it wasn’t.

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Developed a questionnaire for deployment through “healthkiosks”.

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Stage C – Findings (1)

The collated returns from the service user questionnaire provided auseful snapshot of the views of service users who accessed HLPs for allfour services within the study (Early Pregnancy Testing, EmergencyHormonal Contraception, Minor Ailments and Stop Smoking).

• Variability was seen from the responses in the number of consultations for thedifferent services, with a majority of responses from service users who hadaccessed the HLP for the Minor Ailments service.

• However, consideration should be given to the fact that the proportion ofservices users who may complete a questionnaire would be expected to varyby service type.

• Respondents accessing the Minor Ailments service were also more likely to berepeat service users than respondents from the other three service areas.

The majority of respondents were female and most were between 20-49years of age. By far the greatest number of responses was receivedfrom respondents who classified themselves as being from the Pakistaniethnic grouping.

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Overall, there was strong support for the staff member who provided theservice, with a majority of respondents stating that they were seen bythe pharmacist (as opposed to any other pharmacy staff member), butwith slightly fewer stating that they would prefer the pharmacist overother staff members.

There was strong agreement with a series of statements relating to thestaff member the respondent interacted with, indicating that they werehappy with the amount of time the staff member had to deal with theenquiry, how comfortable they felt dealing with that member of staff andindicating a wish to be seen by the same staff member again (see nextslide).

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Turning to the advice provided, again there was strong support for allaspects of the advice, with respondents stating that it was easy tounderstand, that they trusted the advice and that they were satisfied withthe advice (see next slide).


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When examining the service provided compared to what therespondents could obtain from their general practitioner, again there wasstrong support for the services provided through the HLP (see nextslide).

Variability was seen in whether the consultation took place in a privateconsultation room by the type of service accessed.

• Stop Smoking service consultations almost always took place inprivate compared to only half of minor ailment services andconsultations involving pharmacists being more likely to take place ina private room than with other staff members.

• Owing to the variability in the services provided and the likelihood thatthe pharmacist, rather than any other staff member, dealt with themore complex or personal enquiries, this level of variability was to beexpected.

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Just over two-thirds of respondents indicated that they had heard ofHLPs.• This is more than twice the proportion of respondents who reported that they

had heard of HLPs in the national pathfinder evaluation, perhaps indicatingthat awareness of the HLP concept amongst pharmacy users was growing astime progressed.

Similarly, over two-thirds of respondents reported that they were awarethe pharmacy they were in was an HLP, with respondents being morelikely to indicate both that they had heard of HLPs and that they awarethat the pharmacy they were in was an HLP if they were answering fromtheir regular pharmacy.

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Almost half of respondents were aware of the NHS service they usedthrough the pharmacy staff, rather than through other external sources(via their general practice surgery, for example).• This echoes the findings of the national pathfinder evaluation where 44% of

respondents to a questionnaire reported that they were made aware of theNHS service they used by a member of the pharmacy’s staff.


Overall, the views of the service users indicated high levels of supportfor all the services provided and a reassurance that the respondentswere happy with the service provided and the staff members whoprovide the service.

Respondents stated that they would prefer to access these services viatheir local HLP, rather than general practice surgery, and wouldrecommend the services they accessed to friends and family.

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Stage C – Limitations

• The completion of the service user questionnaire was variable across the ten HLPpharmacies within the study and so analysis by individual HLP was not possible.

• The questionnaire was in English and so it may not have been easy for someservice users to engage with the study owing to language barriers, especially takinginto consideration the ethnic diversity found within the centre of Birmingham.

• In addition, it is accepted that response levels may have varied between thedifferent services included in the study as respondents may have felt less inclined tocomplete the study instrument for services relating to, for example, early pregnancytesting and emergency hormonal contraception compared to stop smoking andminor ailments.

• Finally, it should be noted that the questionnaire was only administered to serviceusers (and so the views of the non-service users were not captured).

• In addition, owing to the need to protect anonymity, the data collection methodchosen meant that there was no way to identify the proportion of service usersover the study period who completed a questionnaire and therefore, howrepresentative the views from the respondents are to the general service userpopulation.

A number of limitations were noted:

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Conclusions (1)

The community pharmacies of central Birmingham are located in someof the most deprived areas of England. Their location affords anopportunity to counter the inverse care law whereby those most in needof access to healthcare services are paradoxically those who find it mostdifficult to access such services.

Data from the smoking cessation scheme suggest that participants atHLPs are more likely to have been from sections of society commonlyconsidered to be ‘hard-to-reach’ – men, people from black and minorityethnic groups, those who had never worked or were long-termunemployed and those from the most-deprived areas of centralBirmingham.

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Of particular note in relation to the analysis of the data from the MASwas the large number of items which were supplied via the scheme butwhich are not supported by a robust evidence base.

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Conclusions (2)

This evaluation has revealed no evidence that HLP accreditationimproves activity levels or outcomes in the services examined.

However, data from the MAS suggests that HLP accreditation mayinfluence how participants become aware of the services offered bypharmacy with participants at HLPs being much more likely to reportthat they had heard about the existence of the scheme via promotionalmaterial than participants in non-HLPs.

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This phenomenon was also observed in the service-user questionnairewhere a large proportion of respondents reported hearing about theexistence of the NHS services provided from a member of pharmacystaff.

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Conclusions (3)

Results from the service-user questionnaire suggest that satisfactionwith the services provided by HLPs is very high. Particularly notable arethe high proportions of respondents who reported that they preferred toaccess the service they had used at the HLP rather than at their GPsurgery and the very high proportion of respondents who wouldrecommend the service they had used to their friends and family.

Over two-thirds of respondents to the questionnaire indicated that theyhad heard about HLPs, with the HLP ‘Kitemark’ also being widelyrecognised. The views of service users on the visibility of HLPs were incontrast with those expressed by the pharmacy staff who wereinterviewed as part of this evaluation who believed that awareness ofthe HLP concept amongst their local populations was low

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Conclusions (4)

Amidst discussion of the commissioning landscape, the concern ofpharmacy contractors around remuneration for additional servicesshould be noted. There was a belief that remuneration for such serviceswas insufficient to divert activity away from the dispensing functiontowards patient-centred care.

Whilst such considerations may be outside the scope of local pharmacyand health bodies, strategic level consideration should be given to howremuneration for pharmacies can be altered to support role extensionand the HLP concept.

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A motive for pharmacist engagement with the HLP programme was abelief that accreditation of their pharmacies as HLPs would providereassurance to commissioners that they were consistent deliverers ofhigh quality services

Overview of Recommendations (1)

Further research is recommended to identify whether theuptake of the stop smoking service in traditionally ‘hard-to-reach’ groups via Healthy Living Pharmacies can bereplicated in other geographical areas.

RECOMMENDATION 1:

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Further research is needed to establish whether theexistence of pharmacy-based health services is moreactively promoted in Healthy Living Pharmacies than in non-Healthy Living Pharmacies and whether more activepromotion increases activity levels and improves theoutcomes of such services.

RECOMMENDATION 2:


Any continuation or extension of the minor ailments schemeshould be done in parallel with a review of the itemsprovided via the scheme to ensure that items included aresupported by a robust evidence base so as to minimise anyexpenditure on potentially ineffective interventions.

RECOMMENDATION 3:

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In any future commissioning of services throughpharmacies, consideration needs to be given to the rolepharmacies with Healthy Living Pharmacy accreditation,with their high level of service user acceptance, can offer inthe effective delivery of health care services. Given the lackof randomisation in observational studies, a randomisedstudy – perhaps in the form of a pragmatic clusterrandomised controlled trial – should be conducted toestablish whether HLPs achieve better outcomes than non-HLPs.

RECOMMENDATION 4:

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In order for the number of Healthy Living Pharmacies toexpand and for the number of services offered via HealthyLiving Pharmacies to increase, further consideration needsto be given to the levels of training and support madeavailable to pharmacy staff, especially at the HealthTrainer/Health Trainer Champion level, and the level ofawareness of the programme within the local generalpractitioner population.

RECOMMENDATION 5:

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To ensure the success of any future roll-out of services viaHealthy Living Pharmacies, consideration should be given ata strategic level as to how remuneration for pharmacies canbe altered to support role extension and the Healthy LivingPharmacy concept, along with research conducted at thelocal level to examine the impact of Healthy LivingPharmacy accreditation on non-Healthy Living Pharmacieswithin an area.

RECOMMENDATION 6:

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An Evaluation: The Implementation and Impact of Healthy Living Pharmacies within the Heart of BirminghamPharmacy Practice Research Group

School of Pharmacy

Aston University

http://www1.aston.ac.uk/hlp

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Aston HLP Study Presentation of Results 11.03

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