Summary of the impact

Healthy Living Pharmacies (HLPs) represent a new concept in community pharmacy services designed to meet public health needs through a nationally agreed but locally commissioned tiered framework. The White Paper, Pharmacy in England: Building on strengths, delivering the future, published in April 2008 described the role community pharmacy could play in supporting public health: "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". A national framework for HLPs was developed then ratified by the National Public Health Leadership Forum for pharmacy (PHLFP) in January 2010. This was tested in Portsmouth Primary Care Trust. Findings of the project led to the HLP concept being rolled out across England in 2012 to 20 pathfinder sites (areas, regions, site sounds like an individual pharmacy) involving 100 pharmacies. As of March 2013, there were 478 HLPs across 28 areas and presently there are 721 HLPs in over 35 areas. There are a range of impacts that can be demonstrated from this research including changes to community practice and government policy; increase in public use of pharmacies and improved patient outcomes.

Underpinning research

This work was conducted by Professor Paul Rutter (University of Wolverhampton), Professor David Brown (Portsmouth University) and Professor Jane Portlock (University College, London). The work was undertaken on behalf of NHS South Central which was commissioned by the Department of Health. The research team reported to the National (Government) Research Group for HLP.

1. Development of the national framework

The research team conducted a systematic analysis of international published research on the potential for and impact of delivery of HLP services (Section 3, reference 1), which informed the initial Portsmouth HLP framework, later referred to nationally as the `Portsmouth model'. This work allowed research evidence to inform the services to be offered in the framework and how these services could be delivered that fitted with a `tiered commissioning' philosophy. Commissioning of health promotion and prevention services followed three `levels' of service — level 1 being the entry point to become a HLP. Initial services offered in Portsmouth centred on provision of smoking cessation, weight management, emergency hormonal contraception and harm reduction (e.g. alcohol awareness).

This work informed the local delivery of HLPs in the Portsmouth area (see below). The `Portsmouth model' was amended by the PHLFP subsequent to research findings prior to pathfinder site roll out. This then became the `national framework'.

2. Implementation and analysis of the HLP concept in Portsmouth

All community pharmacies were sent a HLP prospectus and invited to become involved in the project. The prospectus detailed the minimum level of service and staff training required to gain HLP level one status. The credentialing of pharmacies was undertaken by Portsmouth PCT. This involved pharmacists undertaking leadership training and at least one member of non-pharmacist staff becoming a `health champion' by completing The Royal Society of Public Health Level 2 Health Improvement Award. On achieving HLP status, each pharmacy could display an approved logo to highlight to the public that they were a HLP.

The research team gathered data on pre and post HLP service activity, staff and service user opinion. Data was collated from April 2010 onwards through to April 2012.

2.1 Initial evaluation (6 months into the collection period) showed HLPs had higher levels of service activity compared to when they were non-HLPs. They also out performed those pharmacies that had decided not to become HLPs for all services commissioned under the framework. Initial evaluation of staff opinion working in HLPs showed a positive attitude toward the HLP concept. (section 3, reference 2)

2.2 Final evaluation allowed initial findings to be compared with a full set of financial year data (2011-2012). HLP pharmacies outperformed non-HLPs in every service (except provision of emergency hormonal contraception, where there were no significant differences) for the following services:

• A significantly higher median number of clients received medicine reviews for asthma and identified more patients with poor asthma control.
• Significantly more clients set smoking cessation dates and were still non-smokers at 4 and 12 week follow-up.
• 20 clients completed a 26 week weight loss programme through HLPs compared to none in non-HLPs. Nineteen had lost weight with 14 of these (70%) achieving a 5-10% loss in body weight.
• Significantly more alcohol awareness consultations were undertaken through HLPs however there was no difference in the level of uptake by clients regarding subsequent interventions.

2.3 Interviews with staff revealed a positive impact on service development in HLPs, largely engineered through revision of skill mix and additional training of non-pharmacist staff. Sustainability beyond the initial implementation period was proven.

2.4 Public awareness of HLPs was low throughout the study period despite targeted media campaigns. This was attributed to the lack of difference in outward appearance of HLPs compared to non-HLPs (Section 3, reference 3)

2.5 Work is on-going in the Portsmouth region to determine if sustainability as a Level one HLP can be translated in to Level two HLPs — this `tier' allows the HLP to provide extended services compared to a level one HLP (forming part of a PhD study).

References to the research

Note: the journals targeted for this work were selected on the basis that they are international journals that specialise in publishing pharmacy specific work.

Details of the impact

The impact of our research can be seen from two inter-related perspectives:

1. Influence on Government Policy

With positive interim findings (on level of service activity and staff attitudes) and prior to the completion of the study, Lord Howe (Parliamentary Under Secretary of State), wished to see if the same results could be achieved in different areas of England that had different demography and geography.

In response, the national pharmacy bodies (Company Chemist Association, National Pharmacy Association, Pharmaceutical Services Negotiating Committee, Royal Pharmaceutical Society) working together with the Department of Health and Centre of Pharmacy Postgraduate Education collaborated to form a Pathfinder Support Group (PSG) to roll-out the concept nationally. This was a direct result of the findings from our research group.

Expressions of interest to become a pathfinder site were issued in 2011. The intention was to recruit 20 sites involving 100 pharmacies to determine if the Portsmouth experience was scalable. The research team provided expert advice and opinion in to the output measures to be collected. The collation of data from pathfinder sites was overseen by the professional body for pharmacists, The Royal Pharmaceutical Society. Their report on findings from pathfinder sites broadly replicated our findings from Portsmouth PCT and demonstrably shows `proof of concept'.

The HLP concept has now gone beyond the scope of the initial pathfinder programme and is now becoming established as an England-wide model for delivery of public health through pharmacies.

This can be exemplified as there were (as of 31/3/2013) 458 accredited HLPs in 28 regions across England, which has further risen to 721 HLPs by October 2013. This number is set to continue to increase as more regions have expressed a desire to introduce the HLP concept.

The likelihood of sustainability (given the final findings from our research) and the growing number of areas delivering the HLP concept has led to the development of a national training programme offered through The Centre for Postgraduate Pharmacy Education — a government funded training provider for pharmacists (http://www.cppe.ac.uk/learning/Details.asp?TemplateID=HLP-E-00&Format=E&ID=29& EventID=42721) and The National Pharmacy Association hosting dedicated webpages for HLPs (http://www.npa.co.uk/Business-Management/Service-Development-Opportunities/Healthy-Living-Pharmacy/).

2. Impact on the pharmacy profession and health and wellbeing of the public

Our findings (which have subsequently been replicated elsewhere in England) have shown that:

a. Uptake of services through HLPs is higher compared to non-HLPs.

b. Patient outcomes are better (or the same in the case of emergency hormonal contraception) for services delivered through HLPs.

c. Pharmacy teams working in HLPs feel more empowered motivated and better able to deliver public health interventions.

As detailed in reference 3, section 3 and reference 5 in section 5.

The expansion of the HLP concept from 17 pharmacies in Portsmouth in 2009 to 721 across England by 2013 shows that the concept is now a reality. The scalable health benefits to the population at large will mean that HLP pharmacies are contributing to the health of the nation in a more meaningful and demonstrable way than before their introduction.

Sources to corroborate the impact

1. Department of Health, 2008. Pharmacy in England: building on strengths, delivering the future. http://www.official-documents.gov.uk/document/cm73/7341/7341.pdf.
2. Department of Health, 2010. Healthy lives, healthy people: our strategy for public health in England.
   http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127424.pdf.
3. Evans D, Holden M, Morgan L. Pharmacies as healthy living centres: how far down the line have we come? Pharmaceutical Journal 282: 771.
   http://www.pjonline.com/news/pharmacies_as_healthy_living_centres_how_far_down_the_line_ha ve_we_come and further reported at http://www.govtoday.co.uk/pharmacy/15666-public-highly-approves-of-healthy-living-pharmacies-concludes-evaluation-report and http://www.networks.nhs.uk/news/portsmouth2019s-pioneering-healthy-living-pharmacy-initiative.
4. Portlock J, Evans D, Bowhill J, Brown D, Rutter P, Bowhill S. Current thinking on healthy living pharmacies (CPD Module 192) Pharmacy Magazine 2011; 17(10): S1-8.
5. Evans D, Kennington E, Shepherd E, Duggan C, Leach R, Root G, Holden M. Evaluation of the Healthy Living Pharmacy Pathfinder Work Programme 2011-2012.
   http://www.npa.co.uk/Documents/Docstore/Representing-you/Evaluation.pdf.
6. Aston University Healthy Living Pharmacy (HLP) Study. Available at:
   http://www1.aston.ac.uk/hlp/. Demonstrating that HLPs at different sites are coming under independent research scrutiny to add to the body of evidence.