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Contraception access expands

As the NHS Community Pharmacy Contraception Service prepares for national rollout in England, what lessons have been learnt from the pilot and what’s coming next?

Since its launch in September 2021, as of October last year 66 community pharmacists had delivered nearly 1,500 consultations under tier 1 of the NHS England Community Pharmacy Contraception Management Service pilot.

The pilot has freed up capacity in primary care and sexual health clinics by offering patients continuation of supply of oral contraception that has been initiated by a sexual health clinic or a GP.

Ben Morris, pharmacist at Meir Hay Pharmacy in Stoke on Trent in Staffordshire, has been part of the pilot since February 2022, and is preparing to step up to offering tier 2 of the service. This will enable him to initiate supply to eligible patients up to the age of 55 years.

After a slow start seeing just one or two patients a month, Ben briefed a couple of his local GP surgeries about the pilot service to let them know that they could refer any pill checks straight to the pharmacy. “Things rocketed from there,” he says, “but to make the service work you’ve got to get the knowledge out there to the public and get local GPs on board to provide the referrals. 

“One of the reasons GPs have been so keen to refer is that they don’t get any payment as such for doing pill checks, so they are happy to pass patients onto us. So far we have seen 90 patients use the service, with 35 in the last month alone.”

Another way the pharmacy highlighted the service to customers was through staff noting any prescriptions for the pill that came in and letting the patients know that they didn’t have to go back to their GP for a further repeat as the pharmacy could supply it for them instead. 

“Since patients often get 12 months’ supply of the pill at a time, we haven’t seen many repeat prescriptions yet,” says Ben, “but maybe six or seven people have taken us up on this so far. As we always recommend a long-term form of contraception to those we see as part of an EHC consultation, we can also initiate patients via this route once we are in tier 2 of the pilot.”

As with any pilot, participants report back on any parts of the process that aren’t working so well, and for Ben that was the recording element of the service. “I have fed back that one small downside of the pilot stage has been that the consultation module we use for the service creates a follow-up notification for the patient’s GP, which currently involves you typing it out manually to send to the surgery. 

“I’m almost at a point now where I can spend five to eight minutes on a consultation but then there is the paperwork on top of that, so hopefully the national service will use existing systems for recording and notification purposes like most of the other advanced services do, as that would make things even more streamlined for us.”

Contraception service: progress report

In the year 4 and 5 Community Pharmacy Contractual Framework (CPCF) negotiations in England, the Department of Health and Social Care (DHSC) and NHS England proposed commissioning the national pharmacy contraception scheme as an Advanced service, building on the learning that has come from the pilot started in 2021.

NHS England was expected to start rolling out tier 1 of the service this month (January) but this is now not expected to happen until early 2023, perhaps as soon as March.

Although a draft service specification has been published, pharmacy system suppliers needed time to develop the infrastructure needed to support delivery of the service so contractors have fully functioning IT. However, capacity in pharmacy to provide the service remains an issue, says PSNC.

The tier 1 service will involve community pharmacists providing ongoing management of routine oral contraception that was initiated in general practice or a sexual health clinic. The continuation of oral contraception supply from pharmacy will be authorised via a patient group direction (PGD) with appropriate checks, such as measurement of the patient’s blood pressure and BMI undertaken where necessary. The fee for each consultation of £18 and a set-up payment of £900.

Subject to a positive evaluation of the ongoing pilot, which is heading into tier 2 itself, from October 2023 the next phase of the service will be introduced, which will enable community pharmacists to initiate oral contraception supply themselves via a PGD and provide ongoing clinical checks and annual reviews. The fees for tier 2 of the service will be agreed and announced in due course.

If this runs according to plan, NHSE has said the service may then expand into two more subsequent tiers: tier 3, which is the ongoing management of repeat long-acting reversible contraception (LARC), such as implants, vaginal rings, injections and patches; and tier 4, which is initiation of LARC from community pharmacies.

Team involvement

Pharmacy team members are often the first point of contact when it comes to informing patients about the contraception service. Ashleigh Pearce, a pharmacy technician from Newington Pharmacy in Hull, helped get the service up and running in her pharmacy and is part of the team that has delivered the highest number of consultations for the pilot, as well as delivering presentations about the service on behalf of the local NHSE area team.

“We saw our first customer for the service in February 2022 and soon realised we needed to be really proactive as a team to let people know about it,” she says. “We did a search on our PMR system to find when patients’ repeats would be due and called them to let them know about the service and how it worked. Most were already returning every three and six months for their repeats, but once they knew they could get their supply directly from us, they used the pharmacy service and have kept coming back.” 

As a pharmacy technician Ashleigh is not directly involved in delivering the service other than informing customers about it, but says the whole team is aware of what’s happening and can explain it to patients. 

“After we went to the local GP practice to tell them about it, they have also been really keen to send patients to the pharmacy,” she says.

The only problem Ashleigh sees with the service as it gears up for national rollout is a potential lack of wider coverage. “Not every pharmacy will be offering the service, which might mean that patients have to go to a pharmacy that isn’t their usual one to access their contraception,” she points out. 

“We can do walk-ins but operating on an appointment basis works better for us as sometimes we have locums who are not trained to offer the service.” 

“Giving patients an appointment time enables us to know when to expect someone and stops anyone from being disappointed.”

As the pharmacy gears up to offer tier 2 of the service, Ashleigh says the lack of an integrated reporting mechanism back to the patient’s GP surgery is a hurdle that needs to be addressed. “The surgery told us that it doesn’t necessarily need to know but it feels like the system is missing a step here,” she says. 

“On the plus side, our patients definitely love the service as it effectively saves everyone time – as they have to come to us to get their prescription for the pill anyway.”

Desogestrel switch proving popular

September 2021 saw the launch of two OTC oral contraceptive products in community pharmacies after the MHRA approved the POM to P switch of the progestogen-only pill (POP) containing desogestrel. 

Women can now buy Lovima (Maxwellia) and Hana (HRA Pharma) 75mcg tablets after consultation with a pharmacist. 

Both manufacturers cited overcoming the barriers to accessing contraception as a key driver for switching the oral contraceptives, giving women greater choice in how they manage their contraceptive needs. 

Healthcare organisations were broadly in agreement about the benefits for women, with Michelle Riddalls, PAGB chief executive, describing the switch as a “landmark moment” for women’s health in the UK. 

Maxwellia estimates the value of the switch to pharmacies to be around £25m in the first year. Research has shown that women are prepared to pay for the convenience of buying a contraceptive pill from pharmacy, says the company. 

HRA Pharma also says it has seen a positive response to the switch, pointing out that pharmacists had already been supplying desogestrel on prescription for many years so are very familiar with the medicine. 

Great appeal

The appeal of the contraception service from a pharmacy perspective is clear – women don’t need a referral to access it and it is straightforward to administer.

“It is a relatively simple service to provide and pharmacists shouldn’t be put off by thinking it will take too much time to deliver,” says Ashleigh Pearce. 

It has also proved popular with patients, she says. “Yes, doctors can refer people to the pharmacy for the service but we have got more people in by looking at our own patient records and contacting people to come to us that way – and every one of them has come back as it worked well for them and they are happy to use the service again.” 

Ben Morris would certainly recommend pharmacists get involved in the national service, saying that “patient feedback has been really positive all the way through because of the ease and accessibility that pharmacy offers.” His only caveat is that, as with any service offering, it does put more pressure on an already busy workforce. 

“Tier 2 of the service will increase the number of patients we are seeing, so time and staffing are things to consider,” he says. “We have a full-time accuracy checking technician but one of the things going forward is that, although pharmacy is getting more services, we also need funding for staff so we can cope with the extra work.”

While the training requirements needed to offer the service could “initially appear quite daunting” for pharmacists, “if you look at what you have already done in your career, you’ll find you have managed a lot of it already. So don’t be put off – it works well and it definitely makes you feel you are providing more clinical care.”

Having effective conversations about erection problems

There is plenty that pharmacy teams can do to encourage men to talk about their sexual health and, indeed, their health in general. 

Approximately 5 million men in the UK are affected by erection problems (EPs), yet only 4 per cent have spoken to their pharmacist, according to Viatris. And it’s not just older men – a quarter of men under 40 years of age are thought to be affected by EPs. “Erection problems can have a big impact on a man’s wellbeing and self-esteem, causing 31 per cent to feel ‘inadequate’ and 27 per cent to feel like ‘a failure’,” according to Viagra manufacturer Viatris. 

Erectile dysfunction can sometimes be improved with lifestyle changes, such as weight loss, smoking cessation, reducing alcohol consumption, regular exercise and stress management. However, with over 20 years of clinical experience, Viagra Connect (sildenafil) provides an OTC management option offering good tolerability, efficacy and ease of purchase.

A wide range of learning resources supporting sales of Viagra Connect are available on the Pharmacy Magazine website including a guide to having effective conversations with customers, practice scenarios and ways of overcoming potential barriers to purchase. 

Gonorrhoea among the over 60s

With cases of gonorrhoea surging among the over-60s, pharmacy teams are ideally placed to pass on important messages about sexual health to this segment of the population.

The Government’s latest annual sexually transmitted infection (STI) data shows the number of sexual health screens (tests for chlamydia, gonorrhoea, syphilis and HIV) in 2021 increased by 18.7 per cent (from 1,642,598 in 2020 to 1,949,940). 

The total number of new STIs diagnosed in 2021 remained relatively constant at 311,604, with the most commonly diagnosed STIs being chlamydia (159,448; 51.2 per cent of all new STI diagnoses) and gonorrhoea (51,074, accounting for 16.4 per cent of all new diagnoses, up from 50,233 the previous year).

However, the latest age-related STI statistics from the Local Government Association (LGA) show a worrying 20 per cent increase in the number of over-65s in England being diagnosed with common STIs between 2017 and 2019, with figures rising from 2,280 to 2,748. 

Data from the UK Health Security Agency show that while cases rose in both sexes during the three years, figures are substantially higher for men – with 214 men diagnosed with gonorrhoea in 2017, climbing to 360 in 2019. 

What’s behind the surge?

“Gonorrhoea rates are significantly lower in the 65+ age group compared with younger ages,” says Dr Mark Lawton, chair of the British Association of Sexual Health and HIV (BASHH) media group. 

“However, prior to Covid there had been an increase [in the older age group], which is starting to pick up again now. Potential attributing factors are greater use of social dating apps, changes in society attitudes towards sex and relationships, and availability of medication for erectile dysfunction.”

With community pharmacies more easily accessible than other sexual health clinical settings, particularly to people of older age, Dr Lawton says they have an important role in promoting sexual health to this age group. 

“We welcome joint working to promote and normalise positive sexual health,” he says, “with key messaging being that STIs can affect anyone having unprotected sex. We would encourage the promotion of condoms and regular testing to minimise infections, and pharmacy staff can remind customers that sexual health clinics are free and confidential for all ages.” 

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