From Mr P. Walton, MRPharmS
SIR,—The Pharmaceutical Journal of October 14 had three articles concerning
the supply of emergency hormonal contraception. The first of these was the Council’s
approval for standards (p546).
The second was an article indicating that of those pharmacists who would supply
EHC, 86 per cent would prefer to do so using patient group directions, and mentioned
a £15 price tag necessary to pay for pharmacists’ time to give advice
(p584). The third was
regarding the social consequences of sexual encounters, and matters of sex education
(p585).
For the first time ever pharmacists have taken on a properly funded and well
organised prescribing role. The scheme in Manchester, Salford and Trafford was
brought into existence after a suggestion from the health action zone board
that it was an area of urgent need. Many thought that such a controversial scheme
would fail. The reason, in my opinion, that it did not was that it was well
planned and executed. The scheme has withstood all the criticism from varied
pressure groups, and has won overwhelming public support.
We now have the Council publishing guidelines for the sale of EHC in the form
of Levonelle-2. It has put in place a set of conditions for the sale that are
broadly similar to those that would be used by pharmacists supplying under patient
group directions, except for the need for a signed declaration that the consultation
has occurred and each required precondition of supply was fulfilled. In my opinion
this will lead to sloppy practice. There will be no proof that verbal information
was given that the patient had an adequate understanding of EHC before supply.
We will also have proof that age and competence had been discussed before supply;
it will boil down to the patient’s word against the pharmacist’s as
to whether the supply was in accordance with the age guidelines. If pharmacists
do not believe that EHC supply will become degraded to that of any other medicine
without a signature, I ask them to remember those working in busy pharmacies,
who acknowledge everything from a shouted pharmacy medicine sale, to any other
loud statement that appeared to be a P medicine sale with an affirmative response.
Of course, most P medicines are used for self-limiting ailments and if a patient
takes them incorrectly it seldom causes serious consequences. Unwanted babies
are there for a long time, and any litigation is likely to be expensive and
time consuming. It seems ironic that at a time when other health professionals
are being told to document everything in the minutest of detail, the Society
can condone lesser standards of documentation. If a pregnant patient came back
to the pharmacy, solicitor in tow, a few months after supply of EHC and pointed
at the pharmacist saying “that is the man who did not give me full details
which resulted in me becoming pregnant”, how would the pharmacist respond?
I feel that I must address the practicality of maintaining two modes of supply
from pharmacists, one in which the patient pays, and one in which she does not.
One of the great advantages of supply on protocol is that the patient is offered
a comprehensive service at the same cost to her as visiting a general medical
practitioner or clinic. In this situation, the patient does not have to bother
which source of supply she uses, and will often choose pharmacy as the most
convenient option. If pharmacists might charge, or use a protocol, then the
patient might well not go to the pharmacy for fear of having to pay, especially
in the case of the vulnerable poor or young. A minimum necessary cost price
of £15 to supply EHC has been mentioned, which is a lot of money for many
people to find out of the blue. If EHC becomes a pharmacy medicine then there
is always a temptation for budget holders to “encourage” purchase
instead of NHS supply. Encouraging purchase, in effect, means discouraging use
of the free service, and pharmacists are likely to find themselves in no-win
negotiation situations with patients. The easy way out of such situations is
to refuse to supply.
I remain one of the pharmacists who consider we are unlikely to be able to supply
EHC safely if it is afforded a P category licence. Clients will find the pharmacy
that offers least resistance to supply (outside protocol), and consequently
get poorer advice.
Philip Walton
Manchester