| Emergency contraception is the focus of next week’s “Contraceptive
awareness week”, organised by the fpa (formerly the Family Planning
Association). One of the charity’s aims is to promote wider access
to emergency contraception. It lobbied for many years for emergency hormonal
contraception (EHC) to be made available through pharmacies and it fully
supported the
reclassification of Levonelle as a pharmacy-medicine in January 2001.
What Which? says about EHC
Which? researchers asked to speak in private to the pharmacist
and requested EHC. Out of 21 consultations, six were deemed unsatisfactory,
four satisfactory and 11 good. In less than half of the visits
were researchers taken to a private area and, in seven cases, other
staff or customers could overhear the consultation. Most pharmacists
asked the right questions except for two who supplied EHC without
finding out what the researchers judged as important facts, particularly
whether the researcher was taking other medication or might already
have been pregnant. Finally, 13 pharmacists failed to discuss or
give advice about long-term contraception or sexually transmitted
infections. |
So this week’s Which? report (p143) criticising community
pharmacists’ provision
of EHC makes uncomfortable reading. On the plus side, most pharmacists
did ask the right questions before providing the product. What Which? criticised was the fact that in only half the cases were researchers
taken to a private consultation area and that, in the majority of cases,
pharmacists failed to give advice about long-term contraception or sexually
transmitted infections.
Perhaps these criticisms should not come as a surprise. Some similar
conclusions were drawn in 2001 by an evaluation of the EHC service offered
in community pharmacies in the Lambeth, Southwark and Lewisham Health
Action Zone. “The message was that the pharmacy service was hugely
valued and satisfaction ratings with the service were high. However,
people wanted a greater
degree of privacy and clarity over confidentiality,” comments Beth
Taylor, specialist principal pharmacist for community care, London and
South East region. “It is also clear that pharmacists should be
offering advice about sexually transmitted infections when appropriate,” she
adds.
So how can pharmacists improve? And what is the best way for pharmacists
to provide emergency contraception? Supporting evidence
In order to answer this question, it is worth looking at how provision
of EHC in community pharmacy started. Before the non-prescription product
became available,
patient group directions (PGDs) were used to allow pharmacists to supply
EHC without a prescription.
The community pharmacists who have had the longest experience of supplying
EHC are in the Manchester area. A scheme which started as a project to
provide EHC from pharmacies over the millennium holiday has grown and
grown. It allows trained community pharmacists to provide EHC free of
charge under a PGD.
Since the scheme started on 24 December 1999, a total of 68,000 women
have consulted a pharmacist about EHC in the Salford, Manchester and
Trafford Health Action Zone. The scheme now involves nearly 50 sites,
and between 1,400 and 1,600 women are seen each month.
Analysis of the service shows that roughly a third of women are aged
19 years and under, and that the mean age is 22 years, probably reflecting
the large student population in the area. The reason given for needing
EHC is evenly divided between unprotected sex and contraceptive failure.
Karen O’Brien, pharmaceutical adviser and manager of the scheme,
says that only 5 per cent of women requesting EHC fall outside the protocol
used in the scheme. “This shows that 95 per cent of women are self-referring
to the scheme appropriately,” she says.
The Lambeth, Southwark and Lewisham scheme is similar. A survey conducted
last November found that of all women requiring EHC, 27 per cent were
consulting the pharmacist via the PGD route, 27 per cent were purchasing
Levonelle over the counter and 47 per cent were using another service
such as a GP or family planning clinic. This shows that more than half
of patients are choosing to go to the pharmacy. “If the pharmacy
service was not up to scratch then people would still be using other
services more,” says Ms Taylor. In other words, when given a choice,
women are opting to use pharmacies over the other services on offer.
Another audit of the Lambeth scheme conducted last summer compared provision
of emergency contraception at family planning clinics, by GPs, by community
pharmacists and at a hospital-based minor injuries unit. Although it
was looking at the pharmacists offering the PGD service rather than at
OTC sales, Ms Taylor comments: “It provides evidence that pharmacists
who have been trained can provide this service.” The audit showed
that 92 per cent of women were confident that their care at a community
pharmacy was confidential. This compared with 100 per cent at both the
family planning clinic and GP surgery, and 75 per cent at the minor injuries
unit. The audit also showed that women had a good understanding of the
information given about EHC at the community pharmacy, with 92 per cent
saying they understood the information compared with 84 per cent at the
family planning clinic, 84 per cent at the GP surgery and 100 per cent
at the minor injury unit. However, community pharmacies scored lowest
on provision of written information about EHC. A concern raised by Which? was that community pharmacists did not address women’s
ongoing contraception needs. This was not supported by the audit: it
showed that 87 per cent of community pharmacists discussed ongoing needs.
Such discussions occurred in 89 per cent of cases at the family planning
clinic, 50 per cent of cases at the minor injuries unit and 92 per cent
of cases in GP surgeries.
To PGD or pay?
The price of Levonelle – at over £20 – has been criticised
as too high for some women to afford. Price is one of the reasons that
patient group directions continue to be so widely used in order to allow
pharmacists to supply EHC free of charge, particularly in
locations where teenage pregnancy rates and levels of social deprivation
are high.
“Our policy is that EHC should be free to everybody,” says Mrs O’Brien.
So it is hardly surprising that she notes: “OTC sales of EHC are
low in this area.” The Manchester service has no barriers for age
or for where a patient lives: anyone consulting a pharmacist will be
supplied EHC free of charge providing it is clinically appropriate. The
service has agreements with nearby primary care trusts so that payment
will be made for women coming from other areas (women are asked to give
their postcode to identify this).
Mrs O’Brien adds: “We have a strict policy that if a pharmacist
is accredited then he or she must use the PGD to provide EHC. If a pharmacy
does not have an accredited pharmacist present then the first option
is for the client to be referred to the nearest accredited pharmacist.
Only if the client does not want to be referred can the pharmacist sell
EHC.”
This viewpoint is supported by the fpa. “We would like to see wide
provision of EHC under PGDs not just to under 16s but in fact to any
woman who needs it,” says Toni Belfield, director of information
at the fpa.
Manufacturer Schering Health Care plays down criticisms over the price
of Levonelle. First, a spokeswoman points out, it can be obtained free
of charge on prescription. Second, the price of the pharmacy medicine
reflects the amount of training that the pharmacist has had to undergo
in order to supply the product. And, finally, she says that the price
acts a disincentive to using emergency contraception too frequently.
It is important to remember that OTC sales have another advantage. “Some
people choose to buy EHC because it offers complete anonymity,” comments
Ms Taylor.
The Schering spokeswoman notes: “We support the principle of PGDs
because they provide wider access to emergency contraception for women
who are in difficult financial situations or who are younger than the
legal age for purchasing the product.” She adds: “The OTC
product is bought by a different group of women so the impact of PGDs
on OTC sales is limited.”
Who buys the OTC product? The simple answer is older, more affluent women.
The spokeswoman explains that the typical purchaser is aged 26 or 27
years and that the product is mainly bought in urban centres. “The
volume of sales is predominantly in south east England, particularly
London.” A balance between OTC sales and prescriptions for Levonelle
has been more or less reached. Total sales are now at a plateau of 60
per cent prescribed to 40 per cent sold over the counter. How much pharmacist
supply via PGDs contributes to the prescribed figure is unknown. She
adds that the number of PGDs for Levonelle is increasing.
In addition to price, there is another reason why some people prefer
PGDs to OTC sales, and it is a reason that pharmacists may be uncomfortable
with. To provide EHC under a PGD, pharmacists have to be trained and
accredited. They receive support from the scheme’s organisers,
not just in a financial sense but also ongoing guidance. Perhaps this
level of training and support is missing when it comes to OTC sales and
this is reflected in a poorer service for patients identified in the
Which? report. Sexual health advice
One of the Which? report’s main criticisms was that pharmacists
are not giving advice on sexual health when selling EHC.
Under the Manchester scheme, all women consulting a pharmacist about
EHC are offered free condoms and advice about sexually transmitted infections.
Mrs O’Brien believes that not only should EHC be free of charge
but that women should also be offered a pregnancy test, condoms and advice
for free. “If you truly want to reduce unwanted pregnancies then
you have to provide all of these.”
In the future, pharmacists might find themselves with a new role in providing
advice on sexual health. Certainly a greater role in health promotion
is envisaged for community pharmacists as part of the new contract. This
week, the Department of Health announced a major public consultation
about improving public health which will be used to inform a White Paper
on public health due to be published later this year (p146). One of the
areas it will examine is sexual heath. Therefore, this consultation provides
pharmacists with an opportunity to formalise a role in providing advice
on sexual health.
This is something being considered in Ayrshire and Arran Primary Care
NHS Trust, where community pharmacists already provide EHC under a patient
group direction. Andrew McLaughlin, senior pharmaceutical adviser, sees
a new health promotion role for pharmacists. “Supply of EHC is
only part of a wider sexual health strategy. In Ayrshire and Arran we
have set up a group to look at widening the strategy, given that we have
got such a high incidence of teenage pregnancy.”
One possibility being looked at is the supply of free condoms through
community pharmacies. Mr McLaughlin said that he had been concerned that
pharmacists would be worried that this could result in a loss of income: “I
spoke to a group of community pharmacists about this recently. They thought
it was not a big problem since they do not make a lot of money from selling
condoms.”
What would the fpa like pharmacists to offer? “Pharmacists provide
an excellent and convenient source of health expertise for the general
public and they are key players in promoting good sexual health,” says
Ms Belfield. “Pharmacists need to be well trained and supported
so that good quality advice on contraception is given to women without
variation around the country.”
Ms Belfield adds: “It’s also important to remind women about
choice. There is the assumption that when new methods arrive on the market
they replace existing products which are perceived as somehow being inferior.
This simply is not the case. We would like to see pharmacists helping
to better educate women about how many different contraceptive methods
there are.”
If pharmacists want to offer a contraception service that patients are
happy with, they should take note of the Which? report. More needs to
be done to improve pharmacists’ premises so that consultations
can take place in private areas. This might take some time to sort out,
since it raises issues around who will fund such improvements and how
these services will fit into the new contract. What can be tackled now
is the provision of better advice on sexual health whenever and however
emergency hormonal contraception is provided by a pharmacist.
Expanding contraception services further
When it was first proposed to make emergency hormonal contraception
available over the counter, the move was seen as controversial. But
what would pharmacists think about the oral contraceptive pill being
available over the counter? It is not such a far-fetched idea. The
strategy document that outlined a list of potential candidates for
reclassification
from POM to P included oral contraceptives (PJ,
2 February 2002, p131). The document, produced by a number of stakeholders,
including the Royal Pharmaceutical Society, set the agenda for POM
to P switches. The list should be considered carefully: one switch
thought to be far-off at the time the list was published was simvastatin,
and that switch could take place within the next few months.
Schering Health Care has not got any immediate plans to apply for
a POM to P switch for one of its contraceptive pills, but it does
not rule it out for the future. “There is no clear path to
deregulation in sight at the moment. It is very much in the consultation
stage,” says a spokeswoman.
Mrs O’Brien is against making oral contraceptives available
over the counter. She believes that all contraception should be free. “Pharmacists
could supply it using a PGD providing good links were in place with
family planning clinics,” she adds. This could also be a role
for a repeat dispensing service.
One community pharmacist who is hoping to prove that this is just
the type of role that pharmacists can undertake is Therese Findlay,
of
W. Lawson Chemist, Peterhead, Aberdeenshire. She is currently training
to become a supplementary prescriber and plans to use this in a contraception
clinic in her pharmacy. “Patients will come to the pharmacy
for a consultation rather than go to the surgery. I will check the
patient’s blood pressure and weight and find out if they have
been having any problems with the medication,” she says. “If
all is fine then I will issue a prescription.” Prescriptions
are expected to be for six months’ supply, with the GP reviewing
patients once a year. The contraceptive clinic has the full support
of the local GPs: in fact, it was their idea. In addition to easier
access at the pharmacy, another bonus for patients who sign up to
use the supplementary prescribing scheme is that if they miss a pill,
they will be able to be prescribed emergency hormonal contraception
free of charge at the pharmacy. “This is a plus for patients
since the price of EHC is prohibitive,” she adds. |
|
The
Pharmaceutical Journal
