Health and Social Care Committee
HSC(4)-30-12(p5) – 15 November 2012
Inquiry into the implementation of the National Service Framework for diabetes in Wales and its future direction – Evidence from Alliance Boots
A
submission from Alliance Boots
Executive summary
o Community pharmacies play a vital part in the treatment of people with diabetes. They are regular users of pharmacies, in some cases for their whole lives.
o Alliance Boots believes that more emphasis needs to be put on implementing Standards 1 and 2 of the NSF – reducing the risks of developing diabetes; and early identification of people who do not know they have the disease.
o All-Wales arrangements should be put in place to allow pharmacies to support patients with diabetes in four key areas: prevention, early identification, support at diagnosis, and long-term support.
o Pharmacies, with their convenient locations, accessibility and wide reach across the community could deliver services targeted towards at-risk populations, particularly those which are not regularly using GP surgeries.
o Greater support to help patients with medicines, particularly in the crucial first 90 days following diagnosis and the prescription of new medicines, would help increase adherence with long-term treatments
o These pharmacy services should form part of the new Chronic Conditions Service recommended by the Committee in its report on “the contribution of community pharmacy to health care services in Wales”.
Crynodeb gweithredol
o Mae gan fferyllfeydd cymunedol ran hollbwysig wrth drin pobl gyda diabetes. Maent yn defnyddio fferyllfeydd yn gyson, mewn rhai achosion ar hyd eu hoes.
o Mae Alliance Boots yn credu fod angen rhoi mwy o bwyslais ar weithredu Safonau 1 a 2 y Fframwaith Gwasanaeth Cenedlaethol – gostwng y risg o ddatblygu diabetes, a dynodi'n gynnar y bobl na wyddant fod diabetes arnynt.
O Dylid rhoi trefniadau ar waith ar draws Cymru i ganiatáu i fferyllfeydd gefnogi cleifion gyda diabetes mewn pedwar maes allweddol: atal, dynodi cynnar, cefnogaeth adeg diagnosis, a chefnogaeth hirdymor.
O Gallai fferyllfeydd, gyda'u lleoliadau cyfleus, hygyrchedd a chyrraedd eang ar draws y gymuned gyflenwi gwasanaethau sydd wedi'u targedu tuag at boblogaethau mewn risg, yn arbennig rai nad ydynt yn defnyddio meddygfeydd yn rheolaidd.
O Byddai mwy o gefnogaeth i helpu cleifion gyda meddyginiaeth, yn arbennig yn y 90 diwrnod hollbwysig yn dilyn diagnosis a phresgripsiwn am feddyginiaeth newydd, yn helpu i gynyddu cydymffurfiaeth gyda thriniaethau hirdymor.
O Dylai'r gwasanaethau fferylliaeth ffurfio rhan o'r Gwasanaeth Cyflyrau Cronig a argymhellwyd gan y Pwyllgor yn ei adroddiad ar "Cyfraniad Fferylliaeth Gymunedol i Wasanaethau Gofal Iechyd yng Nghymru".
About Alliance Boots
At Alliance Boots, our mission is to be the world’s best pharmacy-led health and beauty group. The group’s businesses in the UK employ over 70,000 people. These businesses include:
o Boots UK pharmacy chain (2,472 stores)
o Boots Opticians (655 practices)
o Alliance Healthcare (Distribution) Ltd, our full-line wholesaler (12 service centres)
o Central Homecare, our clinical homecare specialist division
There are 101 Boots stores in Wales, of which 99 have registered pharmacies. In Wales, our business employs around 2,000 people, including:
o 180 pharmacists
o 280 healthcare assistants
o 30 trainee pharmacists (one-year posts)
Boots pharmacies are well distributed across Wales and are located in places where people live, shop, work and travel, with many open well beyond normal office hours and at weekends. Our chain encompasses those which serve small, local and rural communities, including some of the most deprived locations in the country, through to high streets and those which are part of the largest retail and destination shopping centres.
Alliance Healthcare (Distribution) Ltd is the only UK wholesaler delivering medicines to all pharmacies, dispensing doctors and hospitals. Our Fforestfach service centre in Swansea makes deliveries to pharmacies across Wales. Around 200 people are employed at Fforestfach.
Alliance Healthcare also offers innovative added-value services to its independent pharmacy customers across Wales, such as flu vaccination training, an online service for private prescriptions (Web-prescriptions), support materials for medicines use reviews and for other NHS-commissioned services. Alliance Healthcare also supports Alphega, a pan-European virtual pharmacy network. Alphega has 19 participating independent pharmacies in Wales.
1. The role for community pharmacy in Wales in relation to diabetes
1.1. Community pharmacy has expanded its role in recent years and now provides a wide range of clinical and public health services (NHS and non-NHS) within easy reach of the people who need them most.
1.2. Pharmacists are able to help people maintain and improve their health; providing health messages, advice and services in areas such as physical activity, diet and weight management, stopping smoking, minor ailments and sexual health. Many of these are of particular relevance to people with diabetes.
1.3. Community pharmacies already play a vital part in the treatment of people with diabetes. Alongside healthy diet, medicines are the mainstay of treatment for people with both Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetes. These people are regular users of pharmacies, in some cases for their whole lives.
1.4. Although they receive a good service from pharmacies through getting regular and convenient supplies of the medicines they need, we believe that more could be done to support patients with taking their medication. This is discussed later.
1.5. We also believe that pharmacies should play a much greater role in helping to identify people who do not know that they have diabetes. Many of the early symptoms of diabetes – thirst, tiredness, frequent urination – can seem minor. People may seek relief from symptoms through self-medication or other products bought from pharmacies rather than consult a GP. This gives many opportunities for pharmacies to help with early identification and referral for diagnosis or treatment.
1.6. Pharmacies in Wales have already successfully taken part in public health campaigns designed to raise awareness of the symptoms of diabetes and to screen customers who might be at risk. We discuss later how we think these schemes could be expanded and extended nationally.
2. The progress being made on implementing the NSF for diabetes and its adequacy and effectiveness in preventing and treating diabetes in Wales
2.1. We believe that the care for people with diabetes has improved over the past decade. In part, this can be attributed to the national service framework (NSF), alongside the targeting of diabetes within the Quality and Outcomes Framework (QOF) of the General Medical Services contract for GPs.
2.2. During 2011, over 6.4 million prescriptions items were dispensed in Wales for medicines under the British National Formulary heading of “endocrine diseases” (predominantly diabetes) at a cost of nearly £69m[1].
2.3. Since 2003, the total number of medicines dispensed has risen by 42% to 72.2 million, but the average cost of each item has actually fallen by 23% to £8.14 per item. This is in large part due to the purchasing efficiencies driven by community pharmacies.
2.4. Another key area has been the improvement in treatments, such as new longer-acting insulin products and more sophisticated systems for administering them, and new medicines. Diagnostic equipment, used by patients for the self-measurement of blood glucose levels, has also improved markedly, becoming more accurate and more portable. Recently we have seen these tests being linked to new technologies, including smartphones, to give patients greater control over how they live with diabetes.
2.5. However, we believe that the areas that have not progressed so well since the NSF was launched relate to Standards 1 and 2 – reducing the risks of developing Type 2 diabetes and identifying people who do not know they have the disease.
2.6. In order to reach the ambitions of “Together for Health” for improving health as well as treating illness, the Welsh Government will need to put a much greater focus on prevention and early identification of major chronic diseases. Community pharmacies could play a key role in this.
2.7. The debate around creating a “compact with the people of Wales”, currently out for consultation about initial views, could be one way of increasing this focus. Many of the risk factors for diabetes are inherent from an unhealthy lifestyle – poor diet, lack of exercise, smoking and excessive drinking. Unless the public is also involved with improving its own health, the NHS will be doomed to an unsustainable future of “picking up the pieces”.
3. Potential future actions
3.1. We believe that all-Wales arrangements should be put in place that allow pharmacies to support the implementation of Standards 1, 2 and 4 (patients will receive high quality care throughout their lifetime) within the diabetes NSF. These would focus on four stages: prevention, early identification, support at diagnosis, and long-term support.
3.2. Supporting healthy lifestyles Pharmacies take part in health promotion campaigns organised by Public Health Wales and LHBs. Three of these are now national, which helps in getting bigger public health messages across. We believe that this work needs to be developed in a structured and comprehensive way, similar to the work being done in Scotland through the Public Health Service elements of the pharmacy contract. Pharmacy staff, predominately recruited from their own neighbourhoods, make passionate and trusted advocates for services to aid healthy living, including weight management, smoking cessation and alcohol interventions. Boots pharmacies participated in the national diabetes risk awareness campaign in 2011 and the “One in 10” national campaign on combined stroke and diabetes risk in September 2012. We are pleased that more campaigns are being organised on an all-Wales basis, as this assists with the logistics of distributing materials to our pharmacies and getting feedback from them.
3.3. Early identification Pharmacies should be able to undertake risk assessments and basic tests on customers who might be at risk from diabetes (or other long-term conditions). People would be identified on the basis of self-referral following NHS Wales awareness campaigns or in-pharmacy promotion of the service. Pharmacy staff would also consider customers for assessment on the basis of other interventions, such as consultations for non-prescription medicines or minor ailments. These services would target at-risk populations using the convenience, accessibility and reach of pharmacies, especially for those who are not regular visitors to GPs. Referrals would be made to GPs or appropriate support services, as required. These services do not have to be confined to diabetes alone. The recent “One in 10” public health campaign focused on the estimated one in 10 of the Welsh population at risk from either diabetes or strokes.
3.4. Support at diagnosis Once a patient has had a clinical diagnosis of diabetes (or another chronic condition) there is then a period in which more intensive support is needed to help them come to terms with the diagnosis and its consequences. This would include support for patients who have been prescribed a long-term medication for the first time. Pharmacies should be able to help these patients during the first 90 days through providing support for self-care, signposting local support organisations, providing information, advice and, if necessary, aids or devices to support medicines management and enhance compliance, alongside lifestyle change support.
3.5. Long-term support Once patients have been established on treatment for diabetes, as above [Para 3.4], then there is a continuing need to for support to ensure that they get the best from their medication. This is particularly important when the effects of the disease, or related complications such as high blood pressure, may not be immediately obvious. Pharmacies are already able to undertake annual medicines use reviews (MURs) and to reconcile medicines after discharge from hospital (DMRs) but pharmacies should also be able to support patients on a continuous basis, as necessary, with advice, aids or devices, and/or reminders (such as charts or text messages). Increased adherence should help maintain health and prevent or delay the development of complications, reducing hospital admissions.
4. Recommendations
4.1. Alliance Boots would like to make the following recommendations to the Health and Social Care Committee as part of its inquiry into the implementation of the NSF for diabetes and its future direction:
o Greater emphasis should be placed on implementing Standards 1 and 2 of the NSF (prevention and early identification). Community pharmacies should be involved in delivering this through structured all-Wales services and campaigns
o More support should be given to patients who have been newly diagnosed with diabetes (and other chronic conditions). A service should be put in place to allow pharmacies to support patients through the crucial first 90 days after being prescribed a new medicine
o Services should be developed to support patients on long-term medicines in order to improve adherence and delay complications
o These pharmacy services should form part of the Chronic Conditions Service recommended by the Committee in its report on “the contribution of community pharmacy to health care service in Wales” [May 2012, Recommendation 4, p56]
Response submitted by:
Sian Wilton
Head of Wales
Boots UK
Regional Pharmacy Office
36 Queen Street
Cardiff CF10 2RG
21 September 2012