Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Alliance Boots (DP183)

1. Overview

(a)Alliance Boots’ response addresses questions raised by the Inquiry’s Terms of Reference that focus on: drug treatment as a public health issue; the Government’s approach to service provision; and, the impact of current reforms and how we believe these will impact on the provision of treatment.

(b)The new public health system for England must ensure that effective substitute prescribing treatment is properly funded and that services are accessible and easily available to drug users.

(c)Substitute prescribing treatment substantially reduces deaths, crime, HIV infection and drug use while also assisting social functioning such as improved education, training, parenting and employment.

(d)Community pharmacy has a central role to play in providing integrated, effective treatment and health services to drug users.

(e)Substitute prescribing should be completely patient-driven and dependent on the individual. There should not be an arbitrary time frame imposed on any patient’s medication regime.

2. About Alliance Boots

(a)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, our full-line wholesaler Alliance Healthcare Distribution Ltd, Central Homecare and Alphega Pharmacy—a leading network of independent pharmacists in Europe, with over 600 members currently in the UK.

(b)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. There are approximately 2,500 pharmacies trading under the Boots brand in the UK and these are well distributed across the country. The 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.

(c)Alliance Healthcare Distribution Ltd is the only UK wholesaler delivering medicines to all pharmacies, dispensing doctors and hospitals. It also offers innovative added-value services to its independent pharmacy customers.

(d)Alphega Pharmacy is a leading network of independent pharmacists in Europe. Initially launched in 2001, today it supports more than 5,000 pharmacies across eight countries—the Czech Republic, France, Italy, Spain, Russia, the UK, Germany (vivesco) and The Netherlands (Kring-apotheek). The central aim of Alphega Pharmacy is to help improve the quality of health in communities across Europe by developing a benchmark independent community pharmacy model.

3. Drug User Services provided by Boots UK

(a)Boots UK provides needle exchange and supervised consumption of maintenance treatments to drug users in pharmacies across England, Wales and Scotland. These services are currently available in over 1,200 Boots pharmacies across England—around a third of these pharmacies are also commissioned to provide needle exchange services to drug users. Through drug user services we support around 25,000 service users.

(b)The services help to engage users in drug treatment and reduce drug-related harm and crime via supervised consumption of heroin substitutes and by offering needle and syringe exchange schemes.

(c)Boots also provides drug user services to four prisons in England: in Manchester (Forest Bank), Peterborough, Reading and Staines (Bronzefield). These services operate out of four respective Boots stores, supplying emergency and fridge lines as well as Controlled Drugs and offering medicines management services at the prisons. Additional drugs are also supplied by Central Homecare.

4. The Role for Community Pharmacy in Public Health

(a)The Government has recognised that community pharmacists have a vital part to play in delivering public health—that all healthcare professionals should take advantage of direct contact with patients by asking them about their lifestyle choices, including their diet, smoking, drinking and exercise habits.1 Also that excellent outcomes are possible through effective pharmacy interventions and support, including smoking cessation, weight management and chlamydia screening.2

(b)Over 1.6 million people visit a community pharmacy every day in the UK.3 As recognised in the Public Health White Paper (2011), these interactions are an important opportunity to engage people on their health but also in a more general capacity. The Department for Business, Innovation and Skills recognises that high streets play a crucial role at the heart of our local communities4 and we believe that, by extension, they are important for people to maintain social networks and to be part of their community.

(c)The Government must make full use of community pharmacy in delivering effective public health in England. Pharmacy-delivered interventions have the potential to reach and treat large numbers, including those from minority, ethnic and disadvantaged groups.

(d)Supporting public health interventions requires a long-term commitment, a clear understanding of public health needs locally and expertise in service delivery. Pharmacists have all of these skills and qualities. These extend to the provision of high-quality, effective drug user services.

5. The Holistic Role for Community Pharmacy in Drug User Services

(a)Given the accessibility of community pharmacy, a pharmacist will often be the first point of contact for many drug users who are not in contact with the treatment system. Pharmacists encourage them to regularly access the available provision and also other health and social care services. Pharmacy services also allow users to choose where to receive treatment and maintains a user’s anonymity.

(b)Healthcare services, information and advice: Pharmacists help users to remain healthy until they are ready and willing to cease injecting. Pharmacy staff engage with users and provide advice and information on diet, health, exercise and oral hygiene. Pharmacists can also signpost drug users to treatment services, practical social support, counselling services as well as HIV and hepatitis testing and vaccination services.

(c)Services delivered through community pharmacy offer safe practice and reduce the risk to local communities. For example, needle exchange reduces the practice of sharing equipment amongst injecting drug users by making sterile injecting equipment more easily accessible. The service minimises the risk of exposure of members of the public to contaminated needles and syringes. Needle exchange promotes safer injecting practices and reduces the risk of blood borne virus infection and risk of overdose.

(d)Pharmacists or registered technicians supervise at the point of dispensing in the pharmacy and ensure that the dose is administered. This is undertaken in a designated area of the pharmacy, which provides a sufficient level of privacy and safety. The services optimise the benefits that users can gain from the prescribed medication and ensure compliance with the agreed treatment plan.

Case Study

Claire Barber, Boots Pharmacist and independent prescriber

Claire is a pharmacist and independent prescriber, working in Leeds and Barnsley.

In her job, Claire covers a number of roles, supporting drug users in the community. This includes her work with the Pharmacy Monitoring Programme. The Programme is commissioned by the Drug and Alcohol Action Team, covers Leeds and provides a link between service users and the Community Drugs Treatment Service (CDTS). The programme is facilitated by pharmacists, such as Claire, who interview patients every six weeks and provide feedback to the CDTS: this includes reporting on missed doses, increase in alcohol intake, whether a patient has increased or re-started taking heroin, whether there has been a deterioration of any other medical problems and if the patient wants to increase or decrease their methadone use.

In Barnsley Claire is also involved in a Shared Care scheme, providing support and training to other pharmacists and healthcare professionals. In the Boots store, she holds a clinic once a week, which supports around 20 users, providing dispensing services and offering information and advice. Patients respond well to pharmacists and are more likely to ask them questions and ask for support. For two-days a week, Claire works as part of a larger clinical team in Barnsley, dealing with more chaotic patients. This is also supported by the CDTS and offers services, such as alcohol or methadone detox (in-patient detox and at home), relapse prevention and dry blood spot blood borne virus testing. In Leeds, Claire also provides prescribing support to the local Substance Misuse Team in clinic.

As a pharmacist, Claire regularly works with a number of other health and social care professionals: GPs and nurses, specialist midwives and social services. In addition, she provides specialist training for nurses and ad hoc support for other professionals to share her specialist knowledge and skills.

6. Social, Health and Financial Advantages of Effective Drug User Services

(a)The estimated annual cost to society of problem drug use is £15.3 billion (2003–04 estimate), of which £13.9 billion is the estimated cost of drug related offences. Meanwhile, central and local government spend around £1.2 billion a year tackling drug use in England.5

(b)The services described in Point 5 help reduce the risk to local communities of overuse or underuse of medicines, diversion of prescribed medicines onto the illicit drugs market and accidental exposure to dispensed medicines. Poor treatment and services lead to increased healthcare costs.

(c)Clinical services provided to drug users reduce the risk of contracting infections, causing harm and reduce psychological problems.

(d)Effective interventions could also help limit the size of future generations of drug users.6

7. Plans for Public Health in England

(a)As referenced in the Drug Strategy 2010, the Government, through NHS reform, is putting renewed focus on public health provision in England through a new Public Health System. We welcome the Government’s commitment to address the causes of poor health and to focus on prevention at a population level. The increase of long-standing illnesses and conditions and ongoing pressures on healthcare services, present real challenges. The NHS must use community pharmacy to realise its potential in tackling key public health issues and to increase capacity, availability and accessibility to important public health services.

(b)We also welcome proposals for moving public health responsibilities to Local Authorities. Local expertise and understanding of local population needs will be positive and this extends to drug user services. For example, Directors of Public Health will be expected to engage with a number of stakeholders including NHS colleagues, local schools, voluntary organisations, Police and Crime Commissioners, GP Clinical Commissioning Groups, prison and probation services, local authority and PHE health protection units. A coordinated approach to dealing with drug users will be important to ensure an optimal service is provided.

(c)However, at the same time, several aspects of the new plans for Public Health could be detrimental to drug users and the services designed to support them.

(d)Under the new structure for public health, care for drug users will be disjointed: the NHS Commissioning Board is set to provide screening and prisoner health services, Public Health England will cover immunisation and infectious disease treatment, Local Authorities will have responsibility for drug user and sexual health services, and clinical commissioning groups will look after mental health services. It is not clear how this provision will be coordinated to support a drug user, who might need access to all of these services.

(e)Drug user services require a coordinated approach across different settings to ensure that the right support is in place. For example, when they are released from prison into the community, drug users are at acute risk of drug-related death. There is an important role for community pharmacy to play in supporting patient discharge and their transition into the community.

(f)Based on current levels of spend, drug treatment will account for a significant amount of the public health budget under the new system. The Government will need to ensure sustained investment in these services locally.

(g)The stigma associated with drug users means that services may not be a priority for the new Health and Wellbeing Boards when they make decisions regarding their areas of focus locally. This could impact on the current levels of funding and investment in harm reduction and treatment services.

(h)In light of current NHS efficiency savings and the transition from PCTs to clinical commissioning groups and local authority commissioning, there have already been cases where PCT-commissioned services provided by Boots pharmacies have been ended abruptly—these include methadone supervision services. As noted in the recent Health Select Committee report on public expenditure, focusing on short-term cost savings will not benefit the NHS in the longer term.7

8. Plans for Drug Treatment Outcome Measures

(a)In January 2012 the Department of Health published the Public Health Outcomes Framework, which establishes plans to measure 60 indicators of public health.

(b)The Framework reflects the proposals set out in the Drug Strategy 2010 and includes an indicator that will measure the successful completion of drug treatment—it will measure the number of drug users that leave drug treatment successfully (free of drug(s) of dependence) who do not then re-present to treatment again within six months as a proportion of the total number in treatment.

(c)Alliance Boots supports an abstinence-based approach if that is what the patient chooses and if the patient is at a stage in their treatment journey where they feel they can cope with this approach.

(d)While some patients might suit an abstinence-based approach, the Government must also consider other service users—the most vulnerable people, for whom harm reduction is fundamental—who are dealing with a host of other inter-dependent issues, including alcohol dependency, personality disorders and mental health problems. Beyond health issues, service users will also respond differently based on their living conditions, their employment status and their family structure. There is huge complexity associated with drug users and the Government must be realistic about a one-size-fits-all approach.

(e)This could also lead to a situation where new clients are cherry-picked, based on the need to meet outcomes-based targets. This could also lead to more patients relapsing: starting to use drugs again or requiring a higher maintenance dose of methadone.

(f)Prescribing for substitute treatments should be completely patient-driven and dependent on the individual. There should not be an arbitrary time frame imposed on any patient’s medication regime.

9. Plans for Dispensing Substitute Treatments

(a)Anecdotally we are aware that some commissioners are already looking to reduce the frequency of dispensing of treatment to drug users.

(b)Alliance Boots believes that daily dispensing provides the best level of support for patients: daily contact with the pharmacy team is really important for service users and provides an opportunity to provide support and also for pharmacists to feed back to Drug and Alcohol Action Teams on how patients are progressing with treatment plans. The daily contact provides reassurance and enforces dose consumption on site for patients.

(c)Daily supervision can also be essential if there are any concerns around clinical issues or regarding patient safety. In our experience there are an increasing number of cases where supervised consumption is necessary in light of additional drug taking or problems with alcohol.

(d)In the case of weekly dispensing or pick up it is not clear whether all the methadone has been consumed by the patient. There is a greater risk of poor compliance with the treatment plan—for example, the patient can sell on methadone to fund drug consumption.

(e)There is also a broader public health benefit by ensuring that the methadone is not available to others (including children) and is not released to the market for illicit use.

10. Summary Points

(a)Coordinate care pathways for service users: Ensure that services are coordinated at a national and local level to support patients, who need to access care at different stages across a range of services.

(b)Ensure funding and support for drug user services locally: Within their budgets, Local Authorities and Health and Wellbeing Boards must make provision for effective drug user services.

(c)Maintain daily supervision for patients, where required: Provide the best level of support, appropriate to the individual patient: to maintain compliance with the treatment plan, to provide personalised support to users and to ensure patient and public safety.

February 2012

1 Future Forum report on public health. January 2012
http://healthandcare.dh.gov.uk/forum-report/

2 Healthy Lives, Healthy People, November 2011

3 Future Forum report on public health, January 2012
http://healthandcare.dh.gov.uk/forum-report/

4 BIS healthcheck for High Streets, November 2010
www.bis.gov.uk/news/topstories/2010/Nov/healthy-high-streets

5 National Audit Office—Tackling Problem Drug Use, March 2010

6 National Audit Office—Tackling Problem Drug Use, March 2010

7 Health Select Committee report on Public Expenditure, January 2012:
www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news/report---pex-2-news-/

Prepared 8th December 2012