HC 1048-III Health CommitteeWritten submission from Alliance Boots (PH 126)


Alliance Boots supports the creation of Public Health England (PHE) as part of the Department of Health. PHE will need to have equal status with other parts of the NHS and high-profile leadership in order to put public health at the heart of the newly structured NHS in England.

PHE should take a lead in setting national specifications and standards for public health services that are to be delivered locally across England.

Community pharmacy should be recognised as a key provider of public health services in England. Evidence shows that where the public has a choice of provider for such services, it chooses pharmacies.

Health and Wellbeing Boards should be created as set out in the Health and Social Care Bill and should include representatives of providers of public health services and of national primary care professions (such as pharmacy, ophthalmology and dentistry).

Clear lessons have been learnt about commissioning and providing public health services. It is now time to apply these across England.

The explicit linking of the NHS, social care and public health outcomes frameworks is overdue and is greatly welcomed.

The Department of Health needs to set out clearly which services it regards as “public health” to avoid funds being diverted by local authorities.

About Alliance Boots

Alliance Boots is a leading international pharmacy-led health and beauty group, employing over 70,000 people in the UK. The group’s businesses in the UK include the Boots pharmacy chain and our full-line wholesaler, Alliance Healthcare Distribution Ltd.

Boots UK operates the largest chain of community pharmacies in the United Kingdom. It is synonymous with pharmacy in the public mind and Boots is one of the country’s most trusted brands.

Our company has over 2,200 pharmacies in England trading under the Boots brand. These are located in all the places where people live, shop, work and travel, with many open well beyond normal office hours and across weekends.

Boots pharmacies are well distributed across the country. Our chain encompasses those which serve small local communities, including some of the most deprived locations in the country, and health centres through to high streets and those which are part of the largest retail and destination shopping centres. This provides easy access for the widest range of patients and customers.

Boots offers a wide range of services to help improve public health and individuals’ lifestyles. These include services delivered through the NHS and our own innovative services combining professional advice and medicines.

The range of public health services provided by Boots pharmacies varies with local commissioning but typically will include smoking cessation, sexual health services, health heart checks, weight management, services for drug users (including supervised consumption of prescribed medicines and needle exchange schemes) and vaccinations.

Through a range of interventions, Boots helps the public engage more effectively in their own health and wellbeing: championing prevention, self-care and healthier lifestyle choices.

1. The Creation of Public Health England

1.1 Alliance Boots supports the creation of Public Health England (PHE) as part of the Department for Health. We believe that PHE will provide an important focus and should ensure that public health is at the heart of the newly structured NHS in England.

1.2 In order to achieve this, PHE will need to have equal status to other parts of the new structure, such as the NHS Commissioning Board. PHE will need to be independent and have a high-profile leader who is prepared to speak out on key public health issues and work effectively with other Departments across Government.

1.3 PHE should take a lead in setting national standards and specifications for public health services to be delivered across England.

1.4 It is vital that the NHS responds quickly and effectively to the public health challenge. Clear lessons have been learnt from existing schemes and pilots; it is now time for PHE to apply these across England. Doing so will save the NHS money in both the short and long term.

2. The Abolition of the HPA and NTA

2.1 Alliance Boots sees the proposed abolition of the Health Protection Agency (HPA) and the National Treatment Agency for Substance Misuse (NTA) as arms-length bodies as a retrograde step that should be urgently reconsidered.

2.2 In our view, both organisations have made effective contributions to public health.

2.3 The HPA demonstrated its role in being an active first-responder to public health emergencies during the initial stages of the 2009 H1N1 influenza pandemic. It is unclear to us how this centrally coordinated function would be maintained under the new arrangements. This is especially crucial given that public health emergencies could happen in any part of the country without warning.

2.4 The NTA has helped spread best practice among local drug and alcohol action teams (DAATs), ensuring that there is comprehensive provision of drug misuse services across England. These services benefit public health, cut crime and reduce health and social care costs.

2.5 Pharmacies are heavily involved in providing services to drug misusers. Around half of all Boots pharmacies in England (1,271 of 2,244 stores) provide such services, which include regular dispensing of opiate substitutes as well as other public health interventions.

2.6 Given our comments on the need for greater standardisation for public health services across England [Para 1.3], we are concerned that the abolition of the NTA would lead to greater variation or a dilution of standards in these low-profile areas.

2.7 We urge the Committee to ask Ministers to reconsider and to maintain the HPA and NTA as distinct and separate public health bodies.

3. The Public Health Role of the Secretary of State

3.1 We believe that the aim for future Secretaries of State to have a much greater focus on public health is a laudable one.

3.2 However, we feel that the Secretary of State will need to demonstrate how he can detach himself from the day-to-day politics of the NHS in order to focus on the long-term, population-wide aspects of public health.

4. The Future Role of Local Government in Public Health

4.1 Overall, we support plans to devolve public health responsibility to local government. Local authorities are better placed to give priority to public health matters, many of which are affected by other local issues such as environment, housing, transport and employment.

4.2 However, we believe that this move should be done within a framework of national service specifications and standards. This would avoid unnecessary duplication of effort or the repetition of work previously done for the NHS by PCTs and consequently would prove a more cost-effective way of delivering services.

4.3 The Department of Health needs to set out clearly its definition of public health and, in particular, which services it expects should be funded from the public health budget being allocated to local government.

4.4 Failure to do this clearly will lead to the Government’s attempt to raise the profile and impact of public health services being undermined. Funding for services could simply be diverted away towards other public services, such as environmental health, which could also claim to be “maintaining the public health” (see also comments under Sections 8 and 9).

5. Health & Wellbeing Boards

5.1 Alliance Boots is in favour of Health & Wellbeing Boards (HWBs) being created in the manner envisaged by the White Paper and the Health and Social Care Bill. This would see them becoming committees of local authorities on which commissioning consortia have representation.

5.2 We believe that the alternative proposal put forward by the Health Select Committee in its recent report would actually serve to downgrade the role and impact of public health under the NHS reforms. Merely giving local authorities representation on commissioning bodies would not raise their influence, especially if GPs retain overall control of the commissioning process. Such arrangements would weaken the ability of local authorities to hold consortia to account over their public health roles.

5.3 HWBs will have a statutory duty to include representatives from local authorities and commissioning consortia. We believe that they should also include representatives of providers of public health services and of professions delivering NHS primary care services through national contracts (other than GPs), such as pharmacy, ophthalmology and dentistry. The Bill should be amended appropriately.

6. Joint Strategic Needs Assessments

6.1 Commissioning consortia need to be held to account for their input to Joint Strategic Needs Assessments (JSNAs) and the delivery of Joint Health and Wellbeing Plans (JHWPs).

6.2 This is why we support HWBs being committees of local authorities. Without this independence, the boards will not have enough independence to hold consortia to account.

6.3 All primary care contractors and providers of public health services should be consulted formally over JSNAs and JHWPs, and their comments taken account of.

6.4 Pharmaceutical Needs Assessments (PNAs) form a key part of JSNAs. PCTs were required by law to update their PNAs by February 2011. Further regulations setting out how PCTs should use PNAs to make decisions about new services and applications for new pharmacies (known as “control of entry”) have been delayed by up to two years, despite having been drawn up by expert advisory panel representing all stakeholders.

6.5 The Committee should ask Ministers to bring forward the new pharmaceutical services (control of entry) regulations immediately.

7. Arrangements for Commissioning Public Health Services

7.1 Moving the commissioning of public health services from PCTs to local authorities gives the Government a real opportunity to make a step change in the way these services are delivered and the impact they have on the population’s health.

7.2 In order for this to happen, a full range of national service specifications and standards must be agreed for the key public health services. This will support effective public health delivery, reduce bureaucracy and prevent unnecessary costs being incurred.

7.3 Health promotion and communication—As a major retailer, we know that a coherent message is vital to customer understanding and service uptake. Developing clear national standards allows for the coordinated promotion of services to the public using a range of media and avoids duplication of effort or mixed messaging.

7.3.1The National Audit Office found that PCTs were using up to 45 different marketing campaigns across the country for the same service (National Chlamydia Screening Programme). Such “local inefficiencies and duplications” meant that the programme had “not delivered value for money”, the NAO concluded.

7.3.2Healthy Living Pharmacies in Portsmouth have achieved good results using advertising on local radio and newspapers and the sides of buses. These are not expensive platforms.

7.4 Training and accreditation—Having national standards also allows a much larger pool of trained workers to be created. Local requirements for training and accreditation simply create small pools of trained staff, making service continuity difficult and reducing flexibility for national operators. Having a single agreed standard allows providers to train all their staff to the required level, allowing faster roll-out and making it easier to maintain service continuity.

7.5 Local needs—National standards would allow local authorities to build on a national framework of existing good practice, rather than having to design services from scratch, while taking local needs and priorities into account. They could also build on existing local knowledge and infrastructure for public health services. Community pharmacy is a clear example of this: pharmacies have been providing public health services for over 20 years and there is clear evidence of what works, how to deliver it and its value.

7.6 Co-ordination—A clear set of national standards will also help with joint working between local authorities and commissioning consortia on issues which have both healthcare and public health impact, such as services for drug users or for sexual health.

8. Public Health Outcomes Framework

8.1 The explicit linking of the public health outcomes framework with the frameworks for the NHS and social care is long overdue and is greatly welcomed.

8.2 Domain 2 of the public health outcomes framework covers “tackling the wider determinants of ill health: tackling factors which affect health and wellbeing”. Some of the proposed indicators under this heading are very wide-ranging, including poverty, youth justice, unemployment, violent crime and road casualties.

8.3 We are concerned that this wide focus for the framework may lead to dilution of efforts to tackle core public health issues such as smoking and obesity (see Section 9, below).

9. Arrangements for Funding Public Health Services

9.1 The Government’s commitment to provide ring-fenced public health funding is a major step towards improving these services.

9.2 The Department of Health needs to set out clearly which services it regards as being “public health” for the purposes of this funding (see comments under Section 8, above).

9.3 Having a clear definition will give clarity to public health providers and commissioners about the level of investment that will need to be made in improving facilities or training staff.

10. Community Pharmacy and Public Health

10.1 The Government should recognise community pharmacy as a main provider of public health services under the reformed arrangements for the NHS in England. Clinical public health services are those which involve the supply of a medicine or other intervention alongside professional advice, such as nicotine replacement therapy for smoking cessation.

10.2 Pharmacies are widely distributed and easily accessible. They cross the crucial boundary between NHS healthcare and the wider community—exactly the area that public health services seek to address.

10.2.1By using community pharmacies to provide flu vaccinations, the Isle of Wight was able to reach a much larger group of “at risk” patients in the under-65 age group (36% vs 17% using normal vaccination route of GP surgeries and clinics). This was attributed to the greater accessibility and convenience for this age group of community pharmacies, with their longer and weekend opening hours. “Plurality of providers at different locations will maximise outcomes and benefits for patients,” an analysis of the service concluded.

10.3 Results from the Isle of Wight, the Healthy Living Pharmacies scheme in Portsmouth, and the national Public Health Service delivered through all community pharmacies in Scotland, show clearly that when they have a choice of service provider, people choose pharmacies:

10.3.1In Scotland, prescribing of nicotine replacement therapies (NRT) as part of smoking cessation attempts almost doubled between 2008 and 2010 following the introduction of a national service through community pharmacies. By the end of 2010, nearly two-thirds (63%) of all quit attempts were being made through pharmacies, and over three-quarters in some Health Board areas.

10.4 Boots UK is already a major provider of public health services. However, the fragmented nature of public health service commissioning through PCTs means that, at best, only half of our pharmacies in England are offering a full range of services. This needs to change if the Government is to achieve its desired outcomes for improving the health of the nation.

10.4.1During the 2010–11 flu season, Boots privately vaccinated 70,994 patients at their request in its pharmacies.

10.4.2In the year to March 2011, Boots helped over 81,000 customers with their attempts to stop smoking, of which over 36,000 were successful (45%).

10.5 In conclusion, we believe that through PHE setting clear national standards and service specifications for commissioning public health services, the Government would empower community pharmacy and have a major impact on the health of the population.

June 2011

Prepared 28th November 2011