From Dr N. J. Gray, MRPharmS, and Mrs K. L. O’Brien, MRPharmS
SIR,—Confusion reigns on the streets of Manchester, Salford and Trafford. Regular market research has shown that young adults have increasingly been citing the pharmacy as a place to access emergency hormonal contraception (EHC), but recent responses have been qualified with "But you have to pay for it now, don’t you?".
In our opinion, the decision to deregulate Levonelle-2 benefits neither women nor pharmacists. No charges are currently made to women for contraceptive services from health professionals, including pharmacists in patient group direction (PGD) schemes. Do we need to consider whether we wish to make further local and national representations about this inequitable situation? If we want to act in the best interests of all our clients, how can we move forward constructively in the light of an overtly consumerist move?
The All-Party Pharmacy Group (APPG) was buoyant last week about the Government’s decision to deregulate Levonelle-2. Dr Simon Fradd, from the Doctor-Patient Partnership, was the first to register his concern about the high price, especially when other health professionals supply the product at no charge. Dr Jenny Tonge, MP, a family planning doctor, asserted that the charge would be no problem for most older women who needed the item, and that many younger women would "be able to get the money from their boyfriend or big sister". We do not consider this to be a step forward for women’s control over their own fertility. She also commented that the charge was a good thing because it would discourage repeat use and women would then be referred to GPs and family planning clinics where they could get "better advice about contraception".
Ironically, the APPG meeting was being addressed by Lord Hunt, describing the "Pharmacy in the future"document and implementation plan. One key theme of both the NHS plan and the pharmacy programme is greater access and reduced inequalities. Surely this two-tier system of access to EHC creates a major health inequality for women? If you can pay for it, fine. If you cannot? Sorry, you have to go elsewhere. Another key principle of the pharmacy programme is removal of perverse incentives where pharmacists are paid solely on the basis of items dispensed. Again, pharmacists will only be remunerated for this service if they sell the medicine.
We fear that the excellent PGD schemes that have been initiated in many parts of the country over the past year will be compromised by this decision. The immediate public confusion has already damaged the impact of the scheme in Manchester, if women think that they are now going to be charged. Many will revert to traditional services, and free supply from nurses in walk-in centres will become more attractive.
Pharmacists in PGD schemes can actually help the youngest vulnerable women who will not be able to borrow the money and who are not covered by the licence of the deregulated product. These pharmacists will not have to use "Have you got £20 to pay for this medicine?"as the first question in their consultation. They are people who want to provide this service, and have created time and privacy for it, rather than pharmacists who will feel pressured into stocking a pharmacy medicine against their better judgment. They are formally accredited to provide the service, and have the support of their multidisciplinary family planning team. They are rewarded for giving good advice, independently of whether they supply the medicine or not. In Manchester they are also able to supply free condoms, potentially reducing the incidence of sexually transmitted infections, and refer effectively to other agencies.
In the week after the announcement, two health authorities contacted the Manchester team, explaining that they will definitely now be providing a PGD service because their local population will not be able to afford the pharmacy medicine. But we have a concern that other areas will abandon these schemes, transferring the cost to the client.
It is our opinion that the only way for pharmacists to provide a truly equitable and effective EHC service for women is to ensure that they are part of, or can refer clients to, a PGD scheme in their area, and we would urge local pharmaceutical committees and other service development groups to pursue rapid inception of a scheme. An information pack about the service is available, and can be supplied to any interested party (e-mail karen@obrien2b. freeserve.co.uk). The PGD itself can be accessed via the national PGD website (www.groupprotocols.org.uk). Data from current schemes must be shared to encourage others to invest. We believe that the benefits of rapid access for women to free EHC through community pharmacies, reducing client anxiety and subsequent terminations, will outweigh the cost of funding a properly subsidised and remunerated service. This controversial decision actually underlines the necessity to promote, maintain and extend PGD schemes for EHC.
Nicola Gray Karen O’Brien Founder Project Managers Manchester, Salford and Trafford Health Action Zone EHC Scheme