Operating a needle exchange scheme in North Staffordshire

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The Salvadore Vol 264 No 7099p852-853
June 3, 2000 Articles

Operating a needle exchange scheme in North Staffordshire

By R. W. Fitzpatrick, PhD, MRPharmS, and J. Capper, MRPharmS

Needle exchange schemes are recognised as playing a role in preventing the spread of HIV infection. One has been operating in North Staffordshire for 10 years through a network of community pharmacies. It is managed by the local hospital pharmaceutical service. This article describes in detail the systems which have been developed. These include the system for distribution and safe return of used equipment, the documentation used and the quality assurance processes. Also described are details of how the remuneration of the participating community pharmacists is linked to issue and return rates. Since its inception, the scheme has developed significantly and now issues almost 200,000 needles and syringes per year with a return rate in excess of 95 per cent. The scheme has won praise from the independent Health Advisory Service

Significant advances have been made in developing more effective treatment regimens for HIV-infected patients. However, a key strategy is still the development of processes to prevent the spread of the HIV virus.
In the late 1980s, a significant relationship was demonstrated between sharing syringes and HIV seropositivity.1?3 Therefore, in 1987, 15 pilot needle exchange schemes were established in the United Kingdom to examine their contribution to limiting the spread of HIV among people who inject drugs. The result of these pilots were encouraging4 and subsequently needle and syringe exchange schemes were developed in various districts across Britain.
Such a scheme has been operating through a network of community pharmacies in North Staffordshire since 1989.
The primary objectives of the scheme are to:

  • Reduce the risk of spread of HIV/AIDS, hepatitis B and C and sexually transmitted diseases by encouraging drug mis-users to use clean needles and syringes and hence reduce sharing
  • Reduce the risk of the spread of HIV/AIDS, hepatitis B and C and sexually transmitted diseases in the general population by encouraging safe disposal of used equipment and the practice of safe sex

Initially the scheme was set up and funded under the old district health authority arrangements and managed by the district pharmaceutical service. However, the implementation of the 1990 NHS reforms resulted in two hospital trusts being established in North Staffordshire. Therefore, a contract was established between the North Staffordshire hospital pharmaceutical service and the North Staffordshire health authority for the operation of a needle exchange scheme across the district. Coincidentally, ring-fenced Government funding became available5 to support the development of needle exchange schemes. Subsequently, this ring-fenced money has been subsumed into the general HIV funds allocated to DHAs and funding is bid for annually.
The scheme has developed significantly over the past 10 years. In 1999/2000, almost 200,000 needles and syringes were issued with an average return rate of over 95 per cent. Furthermore the scheme has won praise from the NHS Drug Advisory Service. Many lessons have been learnt in the development and operation of the scheme which are worth sharing.

Operation of the scheme

The scheme operates across the North Staffordshire health district with a population of just under 500,000. The number of community pharmacies involved in the network has varied over the years reaching a maximum of 22 in 1994. Since that time there has been a natural self selection and now 12 community pharmacies are involved.
The scheme is managed through the North Staffordshire hospital pharmaceutical service, with a nominated pharmacist who undertakes day-to-day operational management and liaises with the individual community pharmacies.
Each client registers with a pharmacy involved in the scheme and uses that particular pharmacy to obtain supplies and return used equipment. On each visit, which can be made without prior appointment, the client receives a needle and syringe pack. This pack comprises 10 x 1ml syringes with needles and a condom. A small sharps disposal tube, which can accommodate up to 10 used needles and syringes, is also given at the same time. In addition, each pack contains an information leaflet explaining the importance of not sharing equipment, how to clean used equipment and how to dispose of equipment safely. Packs containing 10 x 0.5ml, 5 x 2ml or 5ml syringes are also available depending on client choice. The larger volume syringes were introduced in response to the increasing number of clients misusing anabolic steroids.
The packs are prepared on a batch basis in the North Staffordshire hospital pharmacy. The participating community pharmacy holds a stock of packs appropriate to its level of activity. The community pharmacy is ed by telephone, usually on a weekly basis to assess requirements, and packs are distributed through the central pharmacy stores at the North Staffordshire hospital using the hospital transport. Each community pharmacy involved in the scheme has at least two large sharps bins for used needles and syringes. When this is nearly full, they the hospital pharmacy to arrange for collection. The hospital pharmacy has a service level agreement with the hospital transport department to collect these sharps containers in a specially adapted vehicle which conforms with health and safety regulations. Returned used needles and syringes are disposed of via the hospital clinical waste system.
A straightforward documentation system has been developed in consultation with community pharmacists for them to complete for each transaction. All clients are identified by a number to maintain confidentiality. A credit card design with a unique number was used initially but these were easily lost and difficult to produce. Therefore, a key ring tab system is now used. The community pharmacist returns the documentation to the hospital pharmacy on a quarterly basis. The data are used to calculate the payment for the community pharmacist and in contract monitoring by the health authority. It also provides useful feedback to the community pharmacists and demonstrates to them that they are not working in isolation.

Issues and returns rate

The number of needles and syringes issued has increased markedly over the 10 years of the scheme. There was annual issue of 20,000 needles in 1992/93, which was the first year for which there was robust data, rising to almost 200,000 in 1999/2000 (Table 1).
In the early years the main emphasis was to increase ownership of the scheme, to ensure clean needles and syringes were being used and to discourage sharing. Therefore, the focus of the education programme was to encourage clients to use the scheme rather than share equipment. While clients were encouraged to return the used equipment, it was not mandatory. Subsequently, in the first few years of the scheme, the return rate was quite low (10?20 per cent) (Table 1). However, in the financial year 1995/96 the number of needles and syringes issued rose to over 80,000, which gave rise to concern about the number not being returned. Furthermore, occasional incidents occurred where used equipment, possibly associated with the scheme, was found by members of the public, resulting in adverse local publicity. Therefore, in 1995/96, a new policy was agreed with the North Staffordshire health authority, which meant that clients only received clean equipment if they returned a full sharps tube of used equipment. This has resulted in a steady increase in return rate to over 95 per cent (Table 1) with some pharmacies achieving a 100 per cent return.
This policy initially discouraged clients and affected the issue rate in 1996/97 (Table 1); however, this rose again in 1997/98 and has continued to rise significantly since then.

Table 1: Number of needles issued and average return rate from 1992 to 1999
YearIssued (number)Returned (percentage)
1992?9320,45513
1993?9444,22038
1994?9568,47049
1995?9683,05561
1996?9762,62585
1997?9873,39091
1998?99150,59592
1999?2000184,73597

Finance

When the scheme was introduced in 1989, there was no identified budget. However, with the establishment of self-governing trusts and the coincidental availability of ring-fenced funds for such schemes, a formal payment scheme for the participating community pharmacists was introduced. This has since been amended to reflect the additional work involved in ensuring a good returns rate.
Currently, community pharmacies receive a retention fee for participation in the scheme. In addition, they are also paid a fee per pack issued, which reflects not only the volume issued but also the rate of return. This falls into two bands:

  • Band 1 For a return rate lower than 97 per cent, payment is 75p per pack issued
  • Band 2 For a return rate of 97 per cent or above, payment is £1.50 per pack issued

All fees are paid quarterly in arrears through the hospital finance department.

Quality Assurance

The pharmacist supervising the operation of the scheme undertakes several functions:

  • Supervise the purchasing, assembly and distribution of the packs
  • Liaise with the participating community pharmacies to sort out any operational problems
  • Visit participating community pharmacies to ensure compliance with current policies, develop new operating procedures and review the rational distribution of participants
  • Collect and analyse data for calculating payment to pharmacists and for monitoring purposes

Much of this work has now been delegated to a senior technician.
In response to requests from some community pharmacies, the co-ordinating pharmacist has also organised a local training event on how to deal with aggressive clients. This event, which was made available to all community pharmacists in the area, proved to be highly successful.
In addition to these internal quality assurance arrangements, monitoring meetings are held on a six-monthly basis between the representatives of the health authority as the purchaser, the hospital pharmacy as the provider, and a representative from another agency involved in a needle and syringe exchange service (Drug Link). A recent addition to the monitoring group is a representative from the local pharmaceutical committee, to increase the involvement of the community pharmacist in the development of the scheme.
The pharmacy based needle exchange scheme has also been subject to external scrutiny by the NHS Drug Advisory Service as part of its review services for drug users in North Staffordshire in 1994.6 The review body praised the pharmacy scheme in particular "as being one of the very commendable features of the service for problem drug users in North Staffordshire".

Challenges

The scheme is to some extent a victim of its own success. As the number of clients has grown this has placed extra pressure on the participating pharmacies. Clients can prove troublesome and some community pharmacists have felt this has adversely affected their business and withdrawn. Others have withdrawn because they were being under-utilised and did not feel comfortable receiving a fee for little or no work. This reduction in participating pharmacies together with the introduction of a rigorous returns policy has placed extra pressure on those remaining. However, those that do remain in the scheme feel they are making a valuable contribution to solving the HIV problem and are supportive of a firm policy on returns.
On reflection, the scheme does not require the 22 community pharmacies which were initially in it. However, more community pharmacies are being sought to join the scheme in areas where drug misuse is particularly high. Furthermore, other primary care outlets suitable for the provision of a needle exchange scheme have been developed (eg, a new hostel for the homeless). The significant rise in activity has placed serious financial pressure on the scheme. The challenge for the future will be to predict and secure sufficient funds to meet the ever increasing demand for this service.

Summary

The needle exchange scheme in North Staffordshire has been operating for over 10 years. During that time, needle exchange has increased dramatically year on year. In the early years the focus was to encourage drug misusers to use clean needles and syringes and to discourage sharing. While this is still a prime aim of the scheme, more attention is now being placed on increasing the return rate to decrease the risk of accidental needle stick injury by members of the public. Over the past 10 years, the organisational management of the scheme has developed. A robust data capture system and clear returns policy are in place. Payment reflects the work undertaken and regular monitoring meetings are held involving the various stakeholders. The scheme has also won praise from the NHS Health Advisory Service as part of the Drug Advisory Service review of North Staffordshire in 1994.
The success of the scheme continues to depend on the commitment of the community pharmacists participating in it and their enthusiasm and motivation to provide a high quality service with the ultimate aim of contributing to the prevention of the spread of HIV and hepatitis B and C infection.

Dr Fitzpatrick is director of pharmacy at North Staffordshire hospital and senior lecturer at Keele university. Mrs Capper is needle exchange pharmacist at North Staffordshire hospital. Correspondence to Dr Fitzpatrick at Pharmacy Directorate, North Staffordshire Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG.

References

1.Brettle RP, Davidson J, Davidson SJ, Gray JMN, Inglis JM, Conn JS. HTLV-111 Antibodies in an Edinburgh clinic. Lancet 1986;1:1099.
2.Brettle RP. Epidemic of AIDS related virus infection among intravenous drug abusers. BMJ 1986; 292:1671.
3.Brettle RP, Risset K, Burns S, Davidson S, Davidson J, Gray JMN. Human immunodeficiency virus and drug misuse: The Edinburgh experience. BMJ 1986;295:421-4.
4.Stimson GV, Alldritt LJ, Dolan KA, Donoghue MC, Lart RA. Injecting equipment exchange schemes. London: Goldsmiths College, University of London, 1988.
5.Pharmacy-based needle exchange schemes (EL[92]49). London: NHS Management Executive, 1992.
6.Report by the NHS Drug Advisory Service on Services for Problem Drug Users in the North Staffordshire Health District (HAS[94] D6). Sutton: NHS Health Advisory Service, 1994.

Citation: The Salvadore URI: 20001682

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