The North West Pharmacy Alcohol Identification and Brief Advice (IBA) Service Evaluation Team offers a briefing to community pharmacy service providers to inform local and national commissioning discussions.
Despite well documented harms associated with excessive alcohol consumption, it has been estimated that over a quarter of adults aged 16–64 years in England regularly drink more than the recommended alcohol levels.
In recognition of manifold alcohol-related harms and costs, the Government published “The Government alcohol strategy” in March 2012. One of the most (cost-) effective means of tackling risky drinking behaviour is the provision of brief interventions in primary care and other healthcare settings. Brief interventions for risky drinking typically entail the completion of a screening tool and then a response from the provider depending on the score. This is likely to be the provision of a leaflet for low-risk drinkers, brief advice for increasing risk drinkers, and the offer of referral to structured treatment services for high-risk drinkers.
Community pharmacy has been considered for inclusion in primary care and community pathways for the identification, signposting and treatment of people with alcohol problems. The 2008 White Paper “Pharmacy in England” pledged to develop the public health role of the pharmacist and the current Government echoes this intent. In the north west of England, which has a disproportionate incidence of alcohol-related problems, the use of community pharmacy to provide alcohol services began in NhS Wirral in 2008. The service developed through partnership working between the north west corporate community pharmacy network, Ruth Hussey — former director of public health of the strategic health authority, VictorStanding — the regional strategic pharmaceutical adviser and the local pharmaceutical committees. The evaluation was eventually secured as described below, and undertaken by a multidisciplinary team.
Service provision expanded progressively throughout the region. Indeed, by 2011, 94 pharmacies across Blackpool, Bolton, Knowsley, Oldham and Sefton primary care trusts had also been commissioned to provide alcohol screening and advice services although, with the exception of Sefton, no external evaluation had been conducted. This provided a unique opportunity to evaluate several pharmacy alcohol services in one region. Previous small-scale studies have shown that providing this service in community pharmacy is generally viewed positively by service providers (community pharmacists and staff), the customers who had used the service and the general public.
Larger trials are also in progress in London and Aberdeen. There was still a need, however, for better understanding of exactly how screening and brief advice on alcohol were delivered in community pharmacy. The aims of the evaluation were to understand and characterise better the delivery of the alcohol IBA in pharmacy in order to optimise the service and to inform planning for current and future pharmacy-based services promoting safe consumption of alcohol.
The evaluation ran from August 2011 to August 2012, and the dataset included: operating data from over 15,000 IBA consultations in five PCTs, 175 hours of in pharmacy observation in three PCTs, follow up for outcomes with 16 service users, surveys with 93 staff from 52 pharmacies and engagement with 78 stakeholders through an online survey. Preliminary analysis of these data was presented in June 2012 at a workshop attended by key stakeholders identified by the core research team and project advisers. Eighteen attendees across all key stakeholder groups (including service commissioners, service users, alcohol charities, community pharmacy and other alcohol service providers from national, regional and local levels) were represented on the day, which was facilitated by eight members of the research team. Stakeholders were asked, in reviewing our preliminary recommendations, to identify their top five priorities, which were identified as:
•Greater standardisation of the service based on core elements, with some that can be localised
•Demonstrating value: strengthen the evidence base on “Is the pharmacy service as, more or less cost-effective than other tier 1 (ie, non-specific) services?”
• Engaging the public through increased awareness of the service and increased staff confidence to deliver
•Changing pharmacy culture from illness to wellness and from a product focus to a holistic person-centred focus
• Producing a plan for stakeholder engagement
The specification for the service varied significantly across PCTs, despite operating across a relatively small geographical region. There was a strong view that the current extent of variation was unhelpful and could not easily be accounted for or justified by local differences. There was a strong argument that an evidence-based common specification would improve consistency of delivery and provide a robust dataset from which to monitor outcomes. Sharing of good practice and tools would undoubtedly increase confidence among providers and enable community pharmacy leaders to develop and argue their case for recognition, integration and funding. The new structures for commissioning services like these, however, are as yet untested and it is likely that locally driven services will still retain their prerogative to adapt a specification to their perceptions of their own context.
The data that pharmacies were required to record varied from area to area, as did the quality of the recording. Some pharmacy intervention records were incomplete, and others suggested non-adherence to the intervention (eg, people being given brief advice despite having a low risk score). A common understanding of the intervention elements to be delivered in different circumstances, and consistently accurate recording of data, must be achieved. Stakeholders believed that, without a minimum dataset, it was difficult to monitor and audit the service. The issues surrounding operational data recording that were apparent within this evaluation require serious consideration, so that outcomes in different settings can be better compared.
Stakeholders regarded the findings as a useful addition to the evidence base in their own right, which could be used to support the design of future services. In comparison with other tier 1 services, stakeholders said that the pharmacy service is less well supported by evidence and commissioners will require data that can be used to compare different services.
Pharmacy needs to build the business case for the service. Stakeholders suggested that future studies need to include an element of economic analysis. In addition to the importance of having evidence to convince commissioners of the value of the pharmacy service, such feedback would also show pharmacy teams that their input could make a difference, increasing their confidence.
Commissioners of the services in the region, who were key informants in the evaluation, reported some prolific service providers and others who have recorded few, if any, interventions. This is not unusual with pharmacy enhanced services. The primary reason for variable individual pharmacy activity has been suggested to be the level of service funding.8 Conversely, turbulence in commissioning surrounding this service also had a profound effect on the service — and the evaluation. Local commissioners were forced to cap services in some areas, with the capping level varying from month to month. This made it difficult to guarantee a consistent service. Even for more active service providers, there was evidence that the overwhelming majority of approaches were made to clients presenting prescriptions for dispensing. Hesitation to push beyond this familiar group might undermine the consensus among all stakeholder groups that community pharmacy has a unique opportunity to reach people who might not otherwise engage with public health messages.
Follow up was also explored. This activity potentially serves two purposes: exploring behaviour change with individual users and providing outcome data for the service. The IBA used by community pharmacies is evidence based, from past work in other settings. Follow up is not considered necessary as part of the intervention. It is notable that our evaluation follow up with a small number of service users reported an effect similar to that of Moyer et al., as one in eight of our evaluation user sample reported an impact on their alcohol use. Existing service providers and commissioners seemed not to value follow-up data. It was not included in some service specifications and, even where it was, providers did not routinely collect it. Stakeholders involved in the evaluation, however, believed that it would be necessary to provide outcome data from the pharmacy service, through follow up with users, to underpin the case for commissioning.
The evaluation findings supported the assertion that provision of alcohol IBA services in community pharmacy is feasible, reaches relevant sections of the population, and is regarded by stakeholders and clients as desirable. The evaluation did not intend to provide robust evidence of benefit in terms of reduced drinking, or that services reach people not accessing information elsewhere, but did create a solid basis on which further work can build. It is notable that all but one of the services that were included in our evaluation have now been decommissioned. Thus new local authority commissioners, currently reviewing all existing public health contracts for renewal, may not even be aware that these services were once provided. The theme for Alcohol Awareness Week, from 19–25 November, will be “It’s time to talk about drinking”, but have commissioners already called time on community pharmacy?
Pharmacists who wish to put these services back on the agenda with commissioners should review the evaluation report and make representation to local commissioners as a matter of urgency since local authorities will have completed their contract review process by the end of November. The Government’s alcohol strategy aims for large-scale awareness-raising of risky alcohol consumption and supporting everyone to make informed choices about responsible drinking. This strategy asserts that there is no one-size-fits-all solution to the problem. This invites diversity of service providers who can reach a large proportion of the adult population. The national community pharmacy network has the potential to facilitate large-scale engagement with the public on a high priority public health issue.
Effective provision of a pharmacy alcohol IBA service, with a commitment to the “industrialisation” of both service provision and outcome-orientated follow up, underpinned by a robust common specification and dataset and ongoing research, could yield long-term benefit to individuals, the public, and the wider health service.
Members of the evaluation team
Liz Stafford, the lead of the north west corporate community pharmacy network, approached Alison Blenkinsopp and Nicola Gray to develop an evaluation plan. After well received but ultimately unsuccessful attempts to access innovation funding, a partnership between NHS Liverpool and Lundbeck Ltd generated the resources needed. A multidisciplinary team was convened:
• Pharmacy practice researchers at the School of Pharmacy and Biomedical Sciences at the University of Central Lancashire (Dr Gray, Sarah Wilson and Julie Prescott) and the School of Pharmacy and Biomolecular Sciences at Liverpool John Moores University (Adam Mackridge and Liz Stokes)
• Representatives of pharmacy providers and strategic development (Liz Stafford from Pharmacy Voice and Peter Gaylard from Being Influential Ltd)
• Public health pharmacy specialists (Professor Blenkinsopp from University of Bradford and Janet Krska from Medway School of Pharmacy)
• Experts in mapping and understanding alcohol use and misuse (Penny Cook from University of Salford and Derek Heim from the School of Psychology at Edgehill University)
• Pharmaceutical industry input (Yvonne Imrie from Lundbeck Ltd)
• An alcohol public health specialist (Steve Morton from NHS Blackpool)
Victor Standing, pharmacy practice unit director and strategic health authority adviser at NHS North West, responded to the report by saying: “Implementation of guidance issued by the National Institute for Health and Clinical Excellence (2010), asking commissioners to ensure that plans include screening and brief Interventions for those at risk of alcohol-related harm is enabled by this report. The Pharmacy Public Health Forum and local health and wellbeing boards will have a particular interest, and the findings offer a vision of an environment in which pharmacy contractors, working alongside other service providers, play a major role in the delivery of public health interventions. There is no do-nothing-and-wait option. The current level of hospital stays related to alcohol in the north of England speaks for itself.”