Review of the Distribution of Healthy Start Vitamins Through Community Pharmacies

7. Barriers and enablers to increasing up-take of Healthy Start Vitamin Tablets and Drops

Despite engaging community pharmacies in the distribution of Healthy Start vitamins, take up has not been high. During the process of conducting the review many issues were raised about wider challenges with the Healthy Start Scheme as a whole (see Appendix 3). This review found a number of factors regarding the distribution of Healthy Start vitamins which contributed to this low uptake. The following sections sets out these factors and includes; distribution systems in place, stock availability, reimbursement system requirements, awareness and understanding about Healthy Start Scheme and the importance of vitamins from intended recipients.

7.1 Existing NHS Health Boards systems and structures

Healthy Start leads indicated that some NHS Boards provide the first tub of vitamin tablets to all pregnant women at booking^[3] along with information on where to get Healthy Start vitamins and drops in the future and how to apply for the Healthy Start Scheme. This enables midwives to have a conversation with pregnant women about what the vitamins are for and how the vitamins can benefit them and their babies. Information is then provided on how women can continue to access the vitamins (for example, via community pharmacy distribution).

Distribution through NHS services enables greater access to vitamin tablets and drops for women and children who are already engaged in health services. This is because NHS services and clinics provide a key contact point for women and children to receive the vitamins in the context of other healthcare provision. However, as the child gets older there are fewer opportunities to distribute the vitamins as the opportunity for contact with NHS services decreases.

While some NHS Boards can relatively easily set up systems for supply and distribution of vitamins though their existing NHS services, other NHS Boards find this more difficult to establish and maintain due the size and geographic spread of their populations (see NHS Greater Glasgow and Clyde box below).

Example: Distributing vitamin tablets and drops in NHS Greater Glasgow and Clyde

Prior to the distribution of vitamins though community pharmacies in 2013, NHS GGC had challenges with distribution through NHS services alone due it its size and challenges with implementing a single system across a large number of CHPs and its relative workforce size. The cost of implementing a system within the NHS was seen to out weigh the cost of implementing through Community Pharmacies. NHS tested distribution through community pharmacies resulting in an overall increase of uptake of vitamin tablets and drops between 2011-13.

7.2 Stock availability

Many community pharmacies responding to the survey indicated continuing difficulties with ensuring they had supplies of vitamin tablets and drops in stock. Problems were identified with wholesalers not having vitamins in stock which was compounded by the short shelf life of the products and the infrequency of requests (with drops having a considerably shorter shelf life than tablets making stock management even more challenging).

"The demand from patients has been sporadic and as a result, we have had some stock go out of date. This resulted in us keeping a low stock, which occasionally meant we ran out when patients required them."

Availability of stock in store is critical for uptake. If community pharmacies do not have stock in store the pharmacy can order more reasonably quickly however this requires women to make a second visit, which may be another barrier to uptake.

Example: Distribution through community pharmacies in NHS Tayside

NHS Tayside worked with community pharmacies along with NHS Fife prior to the pilot to provide support for the distribution of vitamin tablets and drops (providing local step-by-step guides on how the scheme works). However, since the pilot NHS Tayside notes persisting challenges. The first challenge is with health professionals and women knowing where to go to reclaim their vitamins. The second challenge is with community pharmacies understanding how the scheme works and the third challenge is having supplies in stock. Having stock available in pharmacies is a particular issue for NHS Tayside due to its geography (with a mix of rural and urban settings which make distribution through existing NHS Services more challenging). Traveling distances are made more difficult if women may have to travel to more than one community pharmacy to receive the vitamins should they not be available. Although there is a high number of community pharmacies taking part in the pilot, not all community pharmacies have stock in place all the time (particularly where they may not be actively distributing the vitamins on a regular basis). The fact that vitamins have a limited shelf life may not encourage pharmacies to have stock always available (even though money can be reclaimed for out date stock).

7.3 Reimbursement system requirement

Many community pharmacy survey respondents thought the current coupon system for reimbursement is time consuming with the requirement to include the coupon along with a separate prescription [CPUS form].

"The scheme is time consuming for pharmacists to administer - when a coupon is presented then a prescription [CPUS form] has to be handwritten. It would be much better if the coupons could be sent for payment without the need for a prescription to be written."

Many respondents cited problems with women not having the coupons when requesting vitamins and drops.

7.4 Recalling procedures for reimbursement

The reimbursement system for community pharmacies was made more difficult because of the infrequency of requests for the vitamins community pharmacists had to recall what the system for reimbursement was.

"I work in the most socially deprived area of [NHS Health Board], yet the uptake of Healthy Start vitamins had been minimal. To the point that when a request is made, staff always ask 'what do we do here, again?"

7.5 Awareness about Healthy Start Vitamins scheme

Healthy start leads and community pharmacies noted intended recipients may not be aware of the Healthy Start scheme for vitamins. Healthy Start leads commented the amount of information provided at the booking appointment can overwhelm women and information on Healthy Start Scheme can be easily lost. Maternity services are asked to provide a huge range of information as part of the first point of contact and non-clinical issues like Healthy Start seems to get squeezed if there is time pressure.

"The Pharmacy was told we would get a coupon from the patient and then we would write a CPUS for the product(s) required...This has happened few and far between....patients tend to buy them if they want to and patients who would have been eligible seem to not access the service at all"

Although most community pharmacy survey respondents said they provided information to pregnant women on how to take the Healthy Start vitamin tablets and drops (69%) and who is entitled to the Healthy Start Scheme (67%), limited promotion material was available in community pharmacies. Many survey respondents reported keeping vitamins and drops behind the counter. Some Healthy Start leads highlighted this as a potential barrier, requiring women to ask for Healthy Start Vitamins rather than selecting them from the shelf.

7.6 Awareness and understanding about the benefits of Healthy Start vitamins

Healthy Start Leads noted women may not be aware of or understand who should take vitamins, and why taking vitamin tablets and drops are important. Healthy Start Leads report women may have the view that vitamin supplements are not required if women and children are eating a healthy diet. Women and children most at risk of poor health (which vitamins could prevent) are new immigrant populations who are adopting western diets. This is a particular issue for women from ethnic minorities who may not be aware they and their babies have an increased risk of vitamin D deficiency.

Example: Awareness and uptake in NHS Tayside

NHS Tayside has conducted two annual reviews with community pharmacies to explore their experience of the scheme and identify distribution issues with a view to improving up-take. Their review reported high public awareness of the healthy start scheme (74.5% of the 907 respondents knew about the scheme) however a lower response to whether they gave their family vitamin supplements (of the 899 who took part 42.6% did) NHS Tayside noted that uptake of vitamins has not been influenced by the requirement to apply for a means tested benefit or the need to exchange coupons for vitamin tablets and drops. On the contrary, women appear to be comfortable with exchanging coupons for vitamins tablets or drops. However, they noted that uptake may be affected by women's awareness and understanding about whether to take vitamins. Particular challenges have been met where health professionals such as GPs and community pharmacists are not convinced by the evidence that vitamins should be taken as part of a healthy diet (especially with regard to inclusion of Vitamin D).

These women may not be aware of the need to take vitamins or may not be eligible to receive Healthy Start. Uptake may also be influenced by the current evidence underpinning the use of Vitamins such as Vitamin D^[4] (as identified in the NHS Tayside example above).

Healthy Start leads have also expressed concerns that, even where women and children have received Healthy Start vitamin tablets and drops, they may not be taking them.

7.7 Understanding and use of Healthy Start Vitamin Tablets and Drops coupons

Both Community Pharmacies and Healthy Start Leads identified problems in uptake of Healthy Start vitamins due to a lack of awareness and understanding of intended recipients about how to use their coupons.

"Patients don't realise they need a coupon to receive them free of charge."

Coupons are sent by post and then families need to remember to take the coupons into the community pharmacy. The coupons for vitamins are sent our every 8 weeks (whilst food and milk vouchers are sent every 4 weeks). This requires families to detach the vitamins coupon from the food and milk vouchers and take them separately to a community pharmacy as these cannot be redeemed with the same retailers as other healthy start food and milk vouchers (i.e. pharmacies in supermarkets^[5]). These additional steps may mean women are more likely to lose the coupons or give them away with the other vouchers, not realising they are for a separate purpose.

The requirement to present the Healthy Start scheme vitamin coupons at a community pharmacy necessitates women to prioritise vitamins which may be more challenging if they are not aware or understand why they are important and if they are dealing with many other issues in their lives.