In the third of a series of occasional articles, Professor David Taylor from the UCL School of Pharmacy provides a public health oriented view of the ways in which community pharmacists could take on enhanced responsibilities for contraception services.
In the last five years spending on contraception services funded from local authorities in England’s public health budgets has fallen by some 15 per cent in real terms. Yet, according to Public Health England, every £1 spent on contraception will yield £9 in health and social services savings over 10 years. Despite this, a further five per cent cut in local authority funding for contraception services is due this coming year, threatening contraception clinics and aspects of GP care alike.
The 2012 Health and Social Care Act fragmented and weakened the commissioning of sexual and reproductive health (SRH) services. Their financing has consequently become increasingly problematic.
However, if the Government and professional and user groups with responsibilities for improving access to contraception choose to recognise the full role pharmacists can play in this area, and support changes in the laws and funding arrangements determining access to oral contraceptives (OCs), community pharmacy could take a central part in enhancing service provision in all the UK nations.
The UK has a pioneering record in providing contraception (see panel). In global terms, our SRH services remain good – yet there have been weaknesses, most notably in the context of teenage pregnancy rates. In the 1990s British women aged 20 years and under had the highest conception rates in Western Europe. Service improvements introduced by the Blair administration cut pregnancies in this age group by about half in the period to 2010, but there is no room for complacency. British females aged 15-17 years are still up to six times more likely to conceive than their peers in Sweden, Denmark and Holland.
The explanations for such societal differences go beyond service variations. Nevertheless, there is a clear need for continuing action. There is also evidence that provisions for older women require improvement, particularly in the case of those in their 30s and 40s for whom the pill is no longer (or never was) the best choice.
For those seeking to optimise the safety and effectiveness of contraception, it is concerning that the use of long-acting reversible contraceptives (LARCs – including IUDs and other injectable or implantable technologies) is significantly lower in this country than it is, for example, in France.
In much of Europe LARC fitting is conducted by specialist physicians. Women in the UK are often reliant on GP advice and supply. The Royal College of General Practitioners has argued that the fees available for fitting LARCs are often insufficient to justify the time and effort required. It is easier and more cost-effective for GPs to actually prescribe oral contraception.
Most women are satisfied with the contraception advice and support they receive from their GPs and practice nurses. Yet research undertaken at the UCL School of Pharmacy has found that 40 per cent believe that NHS arrangements for supplying contraception to women of their age could be made more convenient.
Over a half of all women agreed with the view that they should be able to obtain the pill directly from their pharmacist, without having to see a doctor or nurse.
Experience in areas such as Lambeth in South London has shown that community pharmacists can safely and effectively play an extended, publicly resourced, contraceptive care delivery role, over and above dispensing and the supply of emergency hormonal contraception and items such as condoms. There is also evidence from the US as well as from poorer nations that pharmacy prescribing, supply and monitoring of oral contraception is viable and desirable.
In the well regulated UK environment there is a robust public interest case for switching OCs to the P medicine category and funding community pharmacists to manage their prescribing and supply. However, pharmacists as individuals cannot unilaterally introduce such changes. The recent Long Term Plan for the NHS also illustrates the fact that bodies such as NHS England are not in a position to lead improvements that would open the way for GPs and their staff using their skills more appropriately to increase LARC uptake.
The key to progress towards extended SRH care provision in community pharmacies lies in the strategies and actions of the pharmacy leadership bodies. No paradigm breaking reform is ever easy but the negotiations about to take place in relation to the contractual framework might offer opportunities for changes in oral contraception supply that no-one could honestly doubt would be in the public’s health interests.
The introduction of affordable forms of contraception from around 1900 accelerated the processes of birth rate decline and health improvement that started around the end of the Victorian era.
Products such as rubber (subsequently latex) condoms and other barrier devices – backed by the use of spermicidal creams, often purchased in pharmacies, and illegal abortion – were followed by the development of IUDs and, from the early 1960s, oral contraceptives.
The pill changed history in that it enabled many more females to enjoy sexual and other freedoms traditionally confined to males. In addition, it allowed them to take part in higher education without losing out in the ‘marriage market’. This in turn let women compete for employment on a more even basis.
In the late 19th century the typical British woman had six babies, but by the 1960s this figure stood at about three, and today it is under two babies per woman. Over the same time the rate of babies dying in their first year of life fell from 150 to four per 1,000.
Such progress has stemmed from scientific and technical advances combined with socio-economic change and the work of committed individuals. Reformers such as Marie Stopes and Helen Brooke helped build a network of contraceptive services which, although under some threat, is still world-leading. Today’s challenge for pharmacists and others is to build on this heritage as cost-effectively as possible.