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AJ Photo/Science Photo Library
EHC has been available for women to buy from
pharmacies since 2001
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Five years ago, amid much controversy, emergency hormonal contraception
was finally launched in an over-the-counter presentation, available from
pharmacies as Levonelle. This followed an announcement by the Department
of Health in December 2000 that Levonelle-2 was to be reclassified
as a pharmacy medicine (PJ, 16 December 2000, p872).
The latest figures from the Office of National Statistics (2004–05)
show that 50 per cent of women who need EHC now obtain it from pharmacies.
In addition, a study published in the BMJ last year showed that, overall,
EHC use has not increased and there has been no fall in the use of regular
methods of contraception. So, has the reclassification of emergency contraception
been a success?
Aim of reclassification
The Government’s aim behind reclassifying EHC was that supply through
pharmacies would increase access to emergency contraception and would,
therefore, contribute to reducing unplanned pregnancies. Levonelle-2,
the prescription-only presentation of levonorgestrel, would continue
to be available free of charge through GP surgeries, family planning
clinics, youth clinics, accident and emergency departments and some community
pharmacies via a patient group direction (PGD).
Reaction in January 2001 to the launch of Levonelle
There were mixed reactions at the time of Levonelle’s launch.
Liam Fox, the then shadow health secretary, told Radio 4’s
Today programme that pharmacists were not trained to supply the
product. In contrast, the Liberal Democrats said that the reclassification
was excellent news and long overdue. The British Medical Association
also supported the move, but believed that the Government had not
gone far enough. It said that it should have made EHC available
to under 16-year-olds, and that it should be free of charge.
The debate on the availability of EHC over the counter was further
fuelled by two undercover investigations by the Daily Mail,
one of which exposed pharmacists selling Levonelle to a girl aged
under
16 years (PJ, 27 January 2001, p101).
Debate in the broadsheets was also rife, with suggestions that
the availability of EHC from pharmacies
would send the wrong message about the need for responsible sexual
activity and openly encourage under-age sex.
EHC hit the headlines again in 2004, when a Which? report criticised
community pharmacists for failing
to provide a satisfactory emergency contraception service (PJ, 7 February 2004, p149).
Perhaps the strongest opposition came from the Society for the
Protection of Unborn Children in the form of a post-hoc legal challenge.
SPUC tried unsuccessfully
to have over-the-counter sales of Levonelle banned under the Offences Against the Person Act 1861 (PJ, 27 April
2002, p558). |
Two-tier service
A PGD scheme in Manchester, initially developed to allow community
pharmacists to provide EHC free of charge over the millennium holiday
period, has
now been up and running for the past six years. Karen O’Brien,
associate director, chronic disease and medicine management at Central
Manchester PCT and manager of the scheme, believes that making EHC
a P-medicine has resulted in a two-tier service. “We never supported
the OTC route. We do not believe that women should have to pay for
emergency contraception when they can get it free on prescription,
or via a PGD,” she says.
The Manchester scheme now provides EHC to around 1,700 women a month
in Salford, Manchester and Trafford. The age of those accessing the service
ranges from 13 to 57 years and over 1,000 pharmacists have been trained
since the scheme started.
Ideally, Mrs O’Brien would like EHC to be available free via a
PGD countrywide. In Manchester, the scheme is being commissioned by the
local primary care trust as an enhanced service under the new community
pharmacy contract. “People have identified accessibility to free
EHC as an at-risk area so we have had lots of phone calls asking about
our training, monitoring, how we accredit pharmacists and how we deal
with situations when the pharmacist isn’t there.”
She believes that the biggest area that pharmacists can get involved
with is supplying EHC to the younger generation. “People who are
under 15 years old do not tend to access the service as much as people
in their 20s,” she says. Pharmacists can only do this via a PGD
since Levonelle is not licensed for use in girls aged under 16 years.
In contrast, Toni Belfield, director of information at the fpa, believes
that it is important that women have a choice of where to obtain EHC.
It is available free from a lot of outlets but some women may wish to
buy it, she says. “Clearly what we wouldn’t want to see is
that women were being forced to buy it. So we would always want to see
services being accessible to women and we want to see some of those services
being improved.” She adds that she would prefer not to see the
price of Levonelle (£25) increase.
For successful provision of EHC from pharmacies it is important to remember
why people go to pharmacies instead of general practice, says Ms Belfield. “They
go because they perceive getting information in a different way, or perhaps
they feel more inhibited with their GP or practice nurse. So when looking
at pharmacy provision, you don’t want to see a duplication of general
practice.” You need to provide services that are client-led but
supported by trained professionals, she adds. Unplanned pregnancies
Although the scheme in Manchester has not resulted in an overall reduction
in the number of unplanned pregnancies, it has reduced the rate at
which they were increasing. “We are told that teenage pregnancy
rates are growing nationally. EHC is part of the solution, but it is
not the answer. There are other things that need to be taken into account,” says
Mrs O’Brien. One thing she has noticed over the past few years
is that womens’ reasons for seeking EHC in Manchester have changed
from condom failure to unprotected sex. This is an area that is currently
being looked at, she says.
Ms Belfield believes that, by definition, EHC must be reducing unintended
pregnancies because of the number of women who are using it. However,
she admits that there are no statistics to suggest that it is reducing
the abortion rate. “Of course it plays a role in reducing unintended
pregnancies but there is still a lot of work to do around delivery, women’s
knowledge and access to EHC.” Future direction
Ms Belfield believes that there is a role for pharmacists in advance
provision of emergency contraception. “Just as women can get
advance supplies now from general practice or from family planning
clinics, one would like to see that possibility [in pharmacies] for
the future.” For this to be successful it is essential that women
know when to use it and how to use it, she adds. |
The
Pharmaceutical Journal