Providing a Sexual Health Service
Goal
To explore the roles that community pharmacy can play in providing a
comprehensive sexual health service to women of child bearing age.
Objectives
After studying this module pharmacists should be able to:
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Describe how community pharmacists can provide contraception, advice and
screening for Chlamydia
Explain how pharmacy based sexual health services can contribute to
reducing the incidence of unwanted pregnancy with specific reference to
unwanted teenage pregnancy
Understand the principles of providing for a sexual health service by
community pharmacists.
Prepare an action plan for premises, staff and systems needed to introduce
(or revise) a sexual health service
Self- Assess your learning needs:
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What additional skills, facilities and equipment would I need to initiate oral
contraception in my community pharmacy?
Is this a service that my PCT would want to commission?
What is the current service provision for sexual health services in my PCT?
What training would I need to provide to my staff to support this service?
How comfortable would I feel discussing all types of contraception?
CPD Competencies - this module supports the following pharmacy
competencies:
Competence
Where the module supports competence development
C1a Assessing the medication needs of
patients
C1c Reviewing medication with patients
C1f Providing advice and counseling,
C1i Generating and maintaining records
of medication supplied to patients
This module provides information on the
assessments required to ensure that a
patient would receive the most
appropriate contraception
In order to identify difficulties and
potential risk e.g. concordance issues,
adverse effects, changing medication
needs
The module focuses on the information
that should be provided by the
pharmacist to a patient to ensure that the
patient knows how to take their
medication.
The module provides information of the
records required for the service to be
provided and information that would be
required by a PCT for audit purposes.
Background
In the Western World the UK has the highest teenage pregnancy rate compared to
the rest of Europe and the USA has the highest rates of teenage pregnancy. It is ten
years since Our Healthier Nation made teenage pregnancy a priority and target for
health authorities with high teenage conception rates (Department of Health 1998)
The Social Exclusion Report 1999 set targets for local authorities to halve teenage
pregnancy rates by the year 2010 and to establish a downward trend in the under 16
rate. This is coupled with the strategy to increase the proportion of teenage parents
in education, training or employment to 60% by 2010 and hence reduce their risk of
long-term social exclusion. All local areas have a 10 year strategy in place with local
under 18s conception rate reduction targets of between 40-60%. These local targets
underpin the national target of 50%.
Reduction in teenage pregnancy is sometimes seen as a political issue however
there are important adverse effects on both health and social as aspects (see Box 1).
Box 1 – Health and social consequences of teenage pregnancy
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Children of teenage mothers have higher rates of infant mortality than
children born to older mothers,
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They are more likely to be born premature – which has serious
implications for the baby’s long-term health – and have higher rates of
admissions to A&E.
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In the longer term, children of teenage mothers experience lower
educational attainment and are at higher risk of economic inactivity as adults;
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The pressures of early parenthood result in teenage mothers
experiencing high rates of poor emotional health and well-being – which
impacts on their children’s behaviour and achievement;
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They often do not achieve the qualifications they need to progress into
further education and, in some cases, have difficulties finding childcare and
other support they need to participate in Education, Employment or Training
(EET). Consequently, they struggle to compete in an increasingly high-skill
labour market.
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Teenage mothers and young fathers disproportionately come from
disadvantaged backgrounds and would, therefore, be more likely to need
additional support to make a successful transition to adulthood, becoming a
teenage parent adds significantly to the challenges they face.
It is estimated that three quarters of under-18 conceptions are unplanned and
around a half end in abortion. It is important, therefore, that there is a strong
focus on preventing teenage pregnancies. Steady progress has been made
on reducing the under-18 conception rate, which has fallen by 11.8% (based
on 2005 data) since 1998, to its lowest level for over 20 years. Within this
overall reduction in conceptions, the rate of births has fallen by almost 19%,
whilst the rate of abortions has fallen by almost 3%.
This means that we are reducing the proportions of young women who
experience early parenthood and the poor outcomes associated with it.
(Source DOH Teenage Parents Next Steps: Guidance for Local
Authorities and Primary Care Trusts 2007.)
Introduction
Community pharmacists across the country have made a significant contribution to
the access and provision of Emergency Hormonal Contraception (EHC) and
contributed to the provision of screening for sexually transmitted diseases. Prior to
these services being introduced there was some scepticism about whether the
pharmacy was a suitable place to provide EHC. However not only are pharmacy
based EHC services regarded as highly successful but there is now recognition of
the significant contribution that can be made to the further development of
contraceptive services by allowing pharmacists to provide regular hormonal
contraception.
In December 2007 in a statement to the House of Lords the Parliamentary UnderSecretary of State, Department of Health, Lord Darzi stated that ‘we recognise that
pharmacies could play an increased role in the provision of contraception and other
sexual-health services because of their accessibility and convenient opening hours.
We will work with primary care trusts over the next year to pilot the supply of
contraception, including the contraceptive pill, through NHS arrangements. We will
also work with the pharmacy profession to ensure robust standard-setting and
appropriate training so that pharmacists are competent to provide this service.’
The Pharmacy White Paper is a consultation document which is seeking the views of
the public, patients and consumers, the NHS and healthcare professionals to feed
into developing a primary and community care strategy due this summer. The White
Paper acknowledges the input that community pharmacists have already provided in
sexual healthcare. In particular pharmacists role in the provision of EHC and
Chlamydia screening. An independent evaluation of a pilot Chlamydia screening
service available across London since November 2005 has shown that 87% of young
people reported that they would recommend the service. Based on this evaluation
the Government intends to publish a national template to support Primary Care
Trusts (PCTs) commissioning of Chlamydia screening from community pharmacies
as part of the National Chlamydia Screening Programme.
(Source: Department of Health ‘Pharmacy in England, Building on Strengths –
delivering the future. April 2008)
This module is able to draw on the experience of the pilot project developed by
Manchester Primary Care Trust for the provision of a Sexual Health Service including
a Patient Group Direction (PGD) by community pharmacists. The Manchester service
is the first in the UK in which pharmacists are initiating oral contraception and thus
provides a model for future services. We anticipate that other primary care
organisations will want to commission this service in the future and this module aims
to give readers an understanding of what is involved.
The Manchester project involves accredited community pharmacists providing
advice, supply and follow up to women who wish to access a family planning service.
The pharmacists are able to supply either condoms or a hormonal method of
contraception (combined oral contraceptive pill or progesterone only pill) or to offer
advice and possible referral to other agencies where appropriate. In addition the
project allows the pharmacist to access the Chlamydia Screening programme for
women under 25 years of age or for any women who wish to access the service
should the need arise. The project also allows the pharmacist to test and treat a
woman (and her partner if appropriate) presenting with a positive result for
Chlamydia under PGD. See the article on page x for further information on
Chlamydia services in community pharmacy.
The purpose of the new service is two-fold. To give women greater choice and
flexibility in accessing services, and to reduce teenage conception rates.
Commissioning of pharmacy based sexual health services
Community pharmacists in Manchester have supplied Emergency Hormonal
Contraception (EHC) under a Patient Group Direction since 1999. Many primary care
organisations now commission this as an enhanced service under the pharmacy
contract and Manchester does so. The local scheme has been very successful with
over 150,000 women accessing the service over the 8 years.
Any pharmacy based sexual health service will be commissioned based on the local
needs identified. The Manchester Teenage Pregnancy Partnership (MTPP)
published a report which identified 17 of wards across the city where the rate of
teenage pregnancy and termination was higher than 60 per 1000 women. In addition
due to the high student population of the city a further ward was included in the
pharmacy service to address the needs of the student population resident during the
academic year.
These areas of greatest need were to be targeted through the new pharmacy
service. Community pharmacists already experienced in providing the existing
Emergency Hormonal Contraception (EHC) scheme under PGD were invited to
become providers of the new service and received training to become accredited to
do so.
Practice Points:
1. Consider if your pharmacy would be identified in such a population area and
whether to approach your PCT
2. Do you already provide EHC under PGD? This is an important consideration
because you will have already undergone role play activities as part of your
accreditation. Also the experience gained providing consultations for an EHC PGD
service is invaluable.
Service Delivery
In order to provide this service there are a number of factors to be taken into
consideration: premises, access, staff, equipment, the consultation, (including
medical history) records/paperwork, training and service audit. Each of these will now
be considered in turn.
Premises
Since the launch of the Pharmacy Contract in 2005, most community pharmacies
now have a consultation room. This is an essential element for the sexual health
service due to the length of a consultation. The average time for an EHC consultation
using a PGD is approximately 10-15 minutes. The new service needs a longer period
for the initial consultation. In addition the service will require storage of confidential
paperwork and some equipment (see below).
(Practice point- how would you manage your consultations for a contraception
service in respect of other services that you may be providing such as MURs or
observed supervised consumption?)
Access to the Service
Part of the consultation process for the Manchester EHC service requires the
pharmacist to discuss future contraception. This is one access point for the new
contraceptive service.
There are other methods to encourage women to access the service which should be
explored, for example:
 emergency supplies of oral contraceptives
 current contraceptive service provision, which may be poor in your area
 current contraceptive service provision which is not easily accessible
 the local GP practice may not have the capacity to provide this service. Your
local surgery may wish to refer women directly to you.
 one advantage of the community pharmacy service is the longer opening
hours including weekends.
Staff
As for any new prospective service your pharmacy staff should be consulted on this
service being provided. You will need to consider how the staff will deal with the
approach by women wanting to access the service and how this information is
relayed to you in the dispensary. You should consider how the service would be
available during sickness and holiday periods. In addition to the counter and
dispensary staff the locum workforce must be consulted. The pharmacy may use a
regular locum or agency staff and these staff should be able to access the required
training.
(Practice point - how would you approach your regular locum/s to engage them with
this service?)
Consideration should be given to the length of time for a consultation. If the
pharmacy is busy at certain times then you may wish to direct staff to operate an
appointments system and how that will be managed e.g. would you issue
appointment cards?
Equipment
In order to safely decide on whether to supply oral contraception the pharmacist is
expected to undertake a number of health checks which requires the following
equipment to be available:
BP monitor
Weighing scales
BMI chart
Height chart
Paperwork
(Practice point – do you have agreements to have pharmacy equipment serviced
regularly?)
The PCT may provide this equipment for you or you may have to purchase this
separately.
The Consultation
As stated above it may be difficult to determine the length of a consultation but you
should allow yourself at least 30 minutes to complete all of the necessary checks and
patient history. It is also dependant on how the client accessed the service e.g. via an
EHC consultation or perhaps referral from another healthcare professional . Another
important factor to consider is whether this is a first supply of hormonal contraception
or a repeat supply. The Manchester scheme uses the same protocol for the supply of
a POP or a COC contraceptive but has a different protocol for the initial and repeat
supplies. The crucial difference between the protocols is to establish where the first
supply of contraceptive was initiated and how long ago since the supply. If the supply
has been within the 12months from the pharmacy then the repeat procedure would
be followed. However if the supply was longer than 12 months then the pharmacist is
advised to use the first issue protocol to ensure the client receives the most
appropriate advice and care.
If the client has accessed contraception from another agency in the past the
pharmacist is responsible for ensuring that all the appropriate checks and advice has
been undertaken during the pharmacy consultation.
Medical History
The most important aspect of this service is taking an accurate medical history from
the client. This history together with the measurements that are undertaken will
inform the decision about the type of contraception that should be considered. A
guide to the consultation is provided below based on the Manchester service:
1. Client history
Name
Date of birth
Address
GP including practice details
Ethnicity
2. Sexual History
Ist day of the last period
Inclusion and Exclusion Criteria
Inclusion Criteria
Have other methods of contraception been discussed including Long Acting
Reversible Contraception (LARCS)?
Does the client have regular periods?
Was the last period normal?
If less than 16 years of age - Does client meet Fraser Guidelines? Is the client
competent to consent to treatment?
3. Exclusion Criteria
Does the client have a known intolerance to oestrogen or progestogens?
Is the client pregnant?
Does the client have any unexplained vaginal bleeding?
Does the client have active liver disease, cholestatic jaundice or a history of jaundice
in pregnancy?
Is there a history of migraine?
Has the client had recent trophoblastic disease?* (this question could be asked as
‘are you undergoing any treatment for a complication of a previous pregnancy?)
Does the client have heart disease or history of stroke?
Does the client have malabsorption syndrome? (this question could be asked as ‘are
you aware of that you have any condition such as coeliac disease or other condition
that might affect you being able to absorb certain foods?)
Does the client have cancer or history of breast cancer?
Is the client receiving concomitant medication which interacts with oestrogen or
progestogen?
* Trophoblastic disease is an uncommon complication of pregnancy where there is
an abnormal overgrowth of all or part of the placenta causing a condition called a
‘molar pregnancy’. It is detected by a rapid rise in the levels of Human Chorionic
Gonadotrophin (hCG). It is recommended that a woman should not use either oral
contraceptives or an IUD during treatment or for some time after to ensure that the
levels of hCG do not rise and lead to confusion. Women are normally registered with
regional centres for on-going treatment. .
4. Lifestyle Information
BP
If BP >140/90 = POP (Progestogen only pill) (i.e. COC would not be
considered appropriate for this patient)
Weight (Kg)
Height (cms)
BMI If BMI >35 = POP
Smoking Status If >35 years & smokes=POP
NB If client is an ex-smoker the date when given up should be recorded including the
average number of cigarettes smoked per day. If it vies less than one year since the
client has given up then the client should be treated as a smoker and counselled that
that the most appropriate form of hormonal contraception is a POP.
5. Deciding which form of contraception is appropriate
All of the above information should be collected prior to a discussion about the
different forms of contraception available. The answers to the above questions would
inform the clinical decision as to which form of hormonal contraception (if any) would
be suitable for this client. You would then need to consider specific exclusion criteria
for the combined oral contraceptive (COC) pill.
(Practice point: what do you think would need to be considered?)
a. Exclusion Criteria specific to a COC form of contraception
Is the client less than six week's post partum or breast feeding?
Does the client have complicated diabetes e.g. nephropathy, retinopathy or
neuropathy?
Is there a history of transient ischaemic attack?
Is there a family history of venous thromboembolism (VTE), myocardial infarction
(MI) or cerebrovascular accident (CVA) in first degree relative <45 years
Is there a history of systemic lupus erythematosus (SLE) or lupus anticoagulant?
Is there a history of acute porphyria?
Does the client have current or past VTE or clotting tendency?
Is there a known presence of gallstones?
Is there a history of long term immobility?
Is client suitable for COC? If YES proceed to Counselling section.
(Practice point: if the answer was no – what would be your next course of action?)
b. POP Exclusion criteria
Does the client have a current VTE or acute porphyria?
NB if YES is answered to this question the client should be referred to Family
planning or GP
Is client suitable for POP? If YES proceed to Counselling section.
If the client is not suitable for either form of hormonal contraception this should be
documented and the client referred to another healthcare professional.
(Practice point- think about how you would deliver this information to a client)
you should be aware of other forms of contraception because the client may be
asking for further guidance.
If the client is suitable for one of the hormonal methods of contraception you should
provide the following counselling which must be documented every time.
Counselling
Efficacy
Mode of action
Effect on menstrual cycle/bleeding
Risk and side effects, breast tenderness, headache, VTE risk
Starting regime
Vomiting and diarrhoea- and what action to take
Enzyme inducing medication
Missed pill advice
Safer sex guidance
Smoking/Alcohol advice
Action if side effects or concerns
Discussion of emergency contraception
Contraception leaflet given
Condoms given
Follow-up appointment
You should stock and be able to supply a range of literature that is available to help
with counselling such as the DH leaflet on the different forms of contraception and
literature on sexually transmitted diseases.
(Practice point- do you already stock this information? If not do you know where to
obtain supplies? The local PCT may be able to provide advice and support for this)
Records and Paperwork
The PCT would in all probability provide the necessary paperwork for audit purposes.
However you may need to consider what information you should record in order to
provide the appropriate advice and supply. In addition to the information recorded
during history taking and counselling the following information should be recorded by
the pharmacist to complete the consultation:
Brand of contraception provided (you should be confident that you have supplied all
of the relevant information for the client to make an informed choice)
Batch number and expiry date
Prescription length e.g. 3 or 6 months
Date of review
The PCT may require that information regarding the supply is supplied to the client’s
regular GP. However patient consent must be obtained before this can occur. The
client and pharmacist should sign and date the paperwork to complete the audit trail.
(Practice point- how would you approach a refusal by a client for this information to
be supplied to the GP?)
An audit form should be completed for the PCT and all documentation stored
following Caldicott Principles preferably in alphabetical order.
(Practice point: think about the different brands of COC and POPs available. Are you
confident to be able to explain about each one? Remember a client may have used a
particular brand before so you must check what, if any, hormonal contraception has
been used before. Also the PCT may specify which brands are to be supplied)
Training
In order to be commissioned to provide the Manchester service community
pharmacists must fulfil the following criteria:
 Accredited to provide EHC
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Undergo further training and accreditation for the new service
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Undergo Enhanced Criminal Record Checks
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Working in wards identified in the Manchester Teenage Pregnancy
Partnership as areas with high teenage pregnancy levels.
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Prepared to commit to providing the service at the pharmacy for a period of
time.
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Be working in a pharmacy which has a consultation room of the standard
required for accreditation under the advanced service of the pharmacy
contract.
The pharmacists will receive additional training delivered by a consultant in sexual
health or similarly qualified clinician such as a GP with Special Interest in Sexual
Health. The supply of hormonal contraception is made under a PGD.
The training includes:
1) The PGDs for the different types of contraceptive pills i.e. Combined Oral
Contraceptive (COC) , Progestogen Only Pill (POP)
2) Chlamydia testing and the PGDs for Chlamydia treatment which include
azithromycin, doxycline and erythromycin
3) Inclusion and exclusion criteria
4) Referral pathways
5) Paperwork
6) Child protection
7) Education in Sexually Transmitted Infections (STIs)
8) How to complete the relevant health checks- i.e. height, weight, calculation of
BMI and BP
9) Role play exercises
10) Multiple Choice Questions
In order to reduce the paperwork Manchester PCT provided the pharmacists with a
CD ROM of the relevant research papers and guidance and each pharmacy with a
copy of the publication, ‘Family Planning: A Global Handbook for Providers 2007’ A
WHO Family Planning Cornerstone publication.
Service Audit
The Manchester service will be evaluated by the PCT after 6 months and is collecting
the following information for audit purposes:
o
o
o
o
o
o
o
o
o
o
Number of women who have accessed the service
Age
Postcode
Method of accessing the service
Type of contraception supplied
Length of consultation
Number of women who have been referred to other services
Number of women who fall outside the protocol
Number of women who are receiving contraception for the first
time
Number of women who are receiving repeat contraception
Post payment verification checks are to be carried out 6 months after the service has
commenced together with a patient satisfaction survey of the service.
Experience to date in Manchester
The Manchester scheme is a pilot project and the 6 months evaluation will take into
account the audit information together with advice and recommendations from the
pharmacists providing the service. The intention is for the pharmacist to use the
paperwork provided by the PCT for 6 months, then re-evaluate to ensure that all the
necessary information has been recorded and to determine the length of time taken
for each consultation.
The service in Manchester used the expertise of some of the most experienced
pharmacists already providing the EHC service. If the new service was to be
provided by a primary care organisation which did not have such a wealth of
experience then consideration should be given to the following:
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Providing training in conducting consultations for contraception
Role play exercises
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Attendance at a family planning clinic to gain experience of the service.
At present most women accessing the new service do so via a request for EHC.
As community pharmacists become more familiar with the project it is expected that
the uptake of women accessing the service will increase.
Reflective activities
What are the targets for your PCT in reducing the teenage pregnancy rate?
Where would you find this information?
What training would you provide to your staff in order to promote this service and
ensure that women are dealt with sensitively?
Multiple Choice Questions.
1. The combined oral contraceptive pill
a. Increases the risk of breast cancer T/F
b. Decreases the risk of breast cancer T/F
c. Increases the risk of ovarian cancer T/F
d. Increase the risk of endometrial cancer T/F
2. Chlamydia is an infection which
a. has higher rates in women taking oral contraception T/F
b. should be treated with azithromycin as a first line treatment T/F
c. has symptoms at the onset of infection
T/F
d. is more common in women over 25 years of age T/F
3. The following contraceptive choices would be appropriate
a. A woman who gave up smoking 6 months ago would be suitable for a
COC? T/F
b. A COC is the most appropriate choice for a woman over 36 years of
age with a BMI of 27?
T/F
c. A POP is suitable for a woman over 29yrs of age who has not had a
period for 38 days?
T/F
d. A COC is more suitable for a woman who works shifts?
T/F
4. A woman taking a COC
a. Should be warned to take extra precautions when taking amoxicillin for
more than 4 weeks T/F
b. Should be advised to stop if she is diagnosed with gallbladder disease?
T/F
c. Can continue with it during major surgery that will cause her to be
immobile for more than 1 week
T/F
d. Is taking the most appropriate form of hormonal contraception with a
BP of 145/93 T/F
5. The Progestogen Only Pill
a. Is the recommended form of hormonal contraception for women who
smoke
T/F
b. Is suitable for a woman taking rifampicin? T/F
c. Can be taken if a woman has migraine headaches with aura T/F
d. Can be supplied if a woman has had a VTE in the last 6 months T/F
6. With regard to contraception, pregnancy and breastfeeding
a. It takes six months from stopping an oral contraceptive for a woman to
become pregnant? T/F
b. A woman who is partially breastfeeding does need to use
contraception?
T/F
c. A POP can increase the risk of ectopic pregnancies? T/F
d. A woman should stop take a ‘rest’ from COCs after taking them for a
long time
T/F
7. A woman should
a. Does not need her BP to be checked at each supply of contraception
T/F
b. Be excluded from taking a POP if her mother had a CVA at 44 yrs T/F
c. Always be offered a choice of which contraceptive? T/F
d. Be advised seek further advice if she has vomiting or diarrhoea for
more than 2 days? T/F
8. During the counselling session the following should occur
a. A woman should be advised to have an STI screening after each
episode of unprotected sex?
T/F
b. All woman should be offered Chlamydia screening? T/F
c. Any type of contraceptive should be started on the fifth day after the
period
T/F
d. Not be supplied with condoms T/F