Specialised, Enhanced Sexual Health Service (Community
Pharmacy)
Incorporating Emergency Hormonal contraception (EHC), Chlamydia screening,
treatment, partner notification, clinic referral and initiation of long acting reversible
contraception (LARC) to women Aged 13 to 19 years
Service Level Agreement
1.
Parties to the Agreement for
This agreement is between:
…………………………………………………………… (“The Pharmacy”) and NHS North of
Tyne (“The Trust”) for the provision of specialised enhanced sexual health
services by the following named authorised pharmacists:
1.………………………………………………………. (RPSGB Reg. No………………)
2……………………………………………………….. (RPSGB Reg. No………………)
3……………………………………………………….. (RPSGB Reg. No………………)
4……………………………………………………….. (RPSGB Reg. No………………)
2.
Aims and intended service outcomes
The purpose of this specialised, enhanced sexual health service is to ensure
equitable and timely access to a comprehensive range of sexual health services
for clients aged 19 years and under who are sexually active delivered in
community pharmacies.
The cost of buying emergency hormonal contraception (EHC), approximately
£25 per course, excludes many clients from accessing EHC via the community
pharmacy. The product licence for over the counter sale further restricts access
of this target group, as sales are restricted to those 16 years of age or over.
This service will contribute to a reduction in the number of unplanned
pregnancies and terminations, amongst teenagers, in line with public health
targets by reducing the barriers to access EHC, and provide a platform to
discuss future methods of contraception by direct referral to the local Sexual
Health Clinic or timely initiation of implantable or injectable long acting
reversible contraception (LARC) as appropriate.
The service and related training will support experienced community
pharmacists, in designated pharmacies work towards the Access Standards
contained in the Department of Health’s “You’re welcome” criteria.
Page 1 of 27
3.
Scope of service to be provided
3.1
Women, hereafter referred to as clients, may self refer, or be referred for
assessment by other professionals.
3.2
All clients requesting EHC from the pharmacists must be informed of the
free scheme.
3.3
Clients may attend solely to request initiation of LARC and/or for Chlamydia
screening and treatment.
3.4
The pharmacist will provide advice and guidance to the client as well as
assessing their suitability for EHC and follow on LARC. This will be according
to the Patient Group Direction (PGD), see appendices 3 and 4. The
pharmacist undertaking the specialised enhanced sexual health service will:

Undertake a comprehensive sexual health history and practice, and
risk assessment.

Provide EHC as appropriate

Provide verbal and written information about all future contraceptive
options to inform choice about future choices.

Give information on safer sex practices and provision of information
on C-Card Condom Distribution Scheme.

Increase uptake of opportunistic Chlamydia screening for 19 years
and under in line with the aims of the National Chlamydia Screening
Programme (NCSP) by provision of testing kit. At the initial
consultation every woman will be counselled about sexually
transmitted infections (STIs) and the NCSP. They must be provided
with a Chlamydia testing kit and advised they may be asked to
return to the pharmacy for treatment and initiation of the partner
notification system if found to be positive.

If requested by Chlamydia Screening Central Office treat clients with
a positive test result and initiate partner notification (PN) for follow
up by NCSP. See appendix IX for care pathway.

Provide verbal and written information on effectiveness, duration of
use, side effects and those symptoms that require urgent
assessment to increase client understanding.

Fitting, monitoring, and checking of contraceptive implants licensed
for use in the UK, as appropriate.

Injection of Depo-Provera® and bi-monthly follow-on injections as
appropriate.

Production of an up-to-date register of clients fitted with a
contraceptive implant and depot injection, to be used for audit
purposes.

Provision of adequate equipment. Certain special equipment is
required for implant fitting. This includes an appropriate room fitted
with a chair and with adequate space, the provision of sterile or
disposable surgical instruments and other consumables, equipment
for resuscitation, and facility for local anaesthesia provision. This
specification includes the provision of sterile or disposable surgical
instruments and other consumables.
Page 2 of 27






Ensure arrangements in place to review clients experiencing
problems with LARC in a timely fashion and the practice able to
appropriately manage nuisance side-effects.
Ensure the client understands the need for the implant to be
removed or replaced within three years, or the need for bi-monthly
follow up injections of depot injection as appropriate.
Production of an appropriate clinical record. Adequate recording
should be made regarding the client’s clinical, reproductive and
sexual history, the counselling process, the results of any STI
screening, problems with insertion, the type and batch number of the
implant and expiry date of the device. Any follow up consultations
should be documented.
An annual audit of the register of clients fitted with a contraceptive
implant; reasons for removal; length of continuation; complications
or significant events should be undertaken and sent to the Clinical
Lead for Contraception and Sexual Health in the PCT.
Each woman must be offered the opportunity to be referred directly
to their nearest Sexual Health Clinic at all stages of the consultation
for STI or contraceptive advice or where there are contra-indications,
see appendix 2 for referral information and documentation.
Chlamydia treatment can be provided to anyone with a positive
Chlamydia screening test result who has requested their treatment to
be provided by a participating community pharmacy.
3.5
Data will be collected on the record form provided which should be
submitted along with the claim form on a monthly basis.
3.6
In addition the pharmacist will ensure that clients are given details of local
services for future use, e.g. Contraception and Sexual Health Clinics (CaSH),
and Genito-urinary (GUM) services. This should also include a brief
description of what each service provides and leaflets as well as information
on effective condom use a pack of condoms and information on where to
obtain condoms via the C-card & Chlamydia Screening and treatment
schemes. Where client consent is obtained complete and submit
contraceptive referral proforma for those clients declining LARC from the
community pharmacist
4.
Service restriction
4.1
This agreement is strictly limited to specifically trained specialised
pharmacists within specific pharmacies identified by The Trust.
The pharmacists must have completed the approved training course and
supportive training material, undertaken mandatory Cardio-Pulmonary
Resuscitation & Anaphylaxis within the previous 12 months hold an
honorary contract with Northumberland Care Trust, have had a CRB check
within the previous three years and have been recognised as competent to
undertake LARC insertion and administration by an RCN approved trainer.
Page 3 of 27
5.
Clinical Governance
5.1
5.2
The pharmacy has a duty to ensure that pharmacists involved in the
provision of the service have relevant knowledge and are appropriately
trained and competent in the operation of the service. Practitioners should
be familiar with the NICE guidance on long acting reversible contraception
and should be working in compliance with this guidance at all times.
Specifically, clinicians should be competent in resuscitation, demonstrate a
continuing sustained level of activity (at least 6 insertion and 6 injections
procedures per year), conduct regular audits and take part in necessary
supportive educational activities, including an annual update session
The pharmacist involved in the provision of the service must be aware of
and operate within local protocols concerning local anaesthetic use,
decontamination procedures and handling of clinical waste. The pharmacy
must have infection control policies that are compliant with national
guidelines including the handling of used instruments, excised specimens
and the disposal of clinical waste.
5.3
The pharmacy must maintain appropriate records to ensure effective
ongoing service delivery, clinical audit and reporting of activity and billing.
5.4
The named pharmacist(s) will:
 Assess clients for suitability of treatment at the time of presentation.
 Obtain and record informed consent for treatment from the client
consistent with Department of Health guidance.
 Provide advice to the client on post-operative care and pain relief.
 Provide any necessary post-operative follow-up, as required.
5.5
The Trust will alert all practitioners providing this service to any urgent
incidents or contraindications relating to implants.
5.6
Confidential records of consultations and competence assessment according
to The Fraser guidelines must be securely retained for three years and nine
months.
6.
Quality Indicators
6.1
6.2
6.3
6.4
6.5
6.6
The pharmacy will provide a mutually convenient time for implant insertion
or depot injection and Chlamydia treatment.
The pharmacy reviews its standard operating procedures and the referral
pathways for the service on an annual basis.
The pharmacist can demonstrate they have undertaken CPD relevant to this
service.
The pharmacy participates in an annual PCO organised audit of service
provision.
The pharmacy conforms to the Decontamination Guidance provided by the
PCT.
The pharmacy co-operates with any locally agreed PCT-led assessment of
service user experience.
Page 4 of 27
6.7
The pharmacy records and investigates any clinical incidents or complaints,
according to the guidance provided by the PCT and provide a written
summary to the Clinical Governance manager at the PCT.
The pharmacy maintains a register of the clients accessing the service being
screened and treated for Chlamydia.
The Pharmacy takes account of the Department of Health You’re Welcome
Standards
6.8
6.9
6.
Clinical exclusions
6.1
7.
Clinical exclusions to EHC or LARC are outlined in respective Patient
Group Direction, but clients may prefer to seek advice from, or be
referred to one of the North of Tyne Specialist sexual health services if
clients have chronic medical conditions or disorders that cause concern.
Agreement Period
7.1
The agreement will commence on dd/mm/2009 to dd/mm/20yy.
7.2
It will be subject to renewal if agreed by all parties and successful
completion of an annual update at Carlton Street Clinic, evidence of
attendance at the Northumberland Care Trust mandatory Cardio-Pulmonary
Resuscitation & Anaphylaxis training workshop.
7.3
The agreement may be terminated, without penalty, if the Pharmacy or
NHS North of Tyne gives the other party one-month notice in writing.
8.
Obligations of the Pharmacy and the Trust
8.1
The Pharmacy must provide the service, delivered by the named
pharmacists, in accordance with the Service specification.
8.2
The Trust will manage the scheme in accordance with the Service
specification.
9.
Terms and Fees
9.1
The pharmacy will be remunerated according to the fee rate set out below,
9.4, uplifted for inflation as agreed each year when the contract is
reviewed. Payment will be made against a monthly claim submitted by the
pharmacy and supporting detail as follows:
 Clients treated identified by :
Age of client
Postcode
 Date of treatment
 Details of consultation/treatment provided to each client
 Consultation/treatment provided by
 Previous form of contraception used
 Remuneration claimed.
 Numbers of clients being screened for and receiving treatment
Chlamydia infection as part of the NCSP
Page 5 of 27
9.2
The pharmacy will bear the costs of:

Consumables used in providing the treatment

Cleaning equipment and the treatment room

Administration of the service

Provision of necessary information to the PCT to audit the contract
and settle invoices.
Client transport costs will not be met by the pharmacy or the Primary Care
Trust.
10.3
Payment will be paid monthly in arrears to the pharmacy on receipt of the
completed relevant signed forms by BACS from NHS North of Tyne direct
into the bank account of the pharmacy. The Community Pharmacy
Record Audit should be completed and submitted to:
Chelsea Harrison
Medicine Management
FAO
NHS North of Tyne
Bevan House
1 Esh Plaza
Sir Bobby Robson Way
Great Park
Newcastle
NE13 9BA
Fax: 0191 217 2506
Description of relevant forms
Form
Number
Form
1
LARC monthly audit sheet
2
Referral proforma for
contraceptive support
3
Summary record of EHC
consultations
4
5
6
7
8
9
Record of consultation for Plan
B (POEC) (Levonelle 1500®)
Assessing competence for
clients according to Fraser
guidelines
Invoice for supply of Plan B
(POEC)
Record of consultation for long
acting reversible contraception
(LARC) – Implanon®/ DepoProvera®
Northumberland, Tyne & Wear
CSP Partner Notification Form
Northumberland, Tyne & Wear
CSP Pharmacy Treatment
Sheet
location
To be submitted monthly to
NHS North of Tyne
Appendix I
To be faxed to relevant
Sexual Health Service as
appropriate
Appendix II
To be submitted monthly to
NHS North of Tyne
Appendix III
To be retained within the
Pharmacy for 3 years
Appendix IV
To be retained within the
Pharmacy for 3 years
Appendix V
To be submitted monthly to
NHS North of Tyne
Contained within each
specific PCO Plan B SLA
To be retained within the
Pharmacy for 3 years
Appendix VI
To be faxed to NTWCSP
Central office as appropriate
Appendix VII
To be faxed to NTWCSP
Central office as appropriate
and NHS North of Tyne
Appendix VIII
Page 6 of 27
10.4 Banking details
Banking details
Name of Bank
Address:
Sort Code
Account Number
10.5
Fee structure
Description
Fee
Plus drug
cost (Drug
Tariff + VAT)
Plan B consultation fee
£7.00
N/A
3
Supply of EHC
£5.50
Yes
3&6
£4.50
N/A
Payment made
automatically
monthly in arrears.
£4.50
Yes
8&9
Yes
1
Yes
1
Yes
1
Receipt of Chlamydia screening
test by Microbiology
Department1
Chlamydia treatment and PN
initiation
(plus drug cost)2
Insertion of the Implanon®
device
(plus drug cost)2
Initiation of Depo-Provera®
Follow up Depo-Provera®
injection
(2 monthly intervals)
10.
2
£60.00
£30.00
(plus drug cost)2
£7.00
(plus drug cost)2
Resolution of disputes
10.1
1
Form to be
submitted to
make claim
It is expected that any disputes will be resolved between the pharmacy and
the PCT. However, in the event that they cannot, the dispute will be
referred to an arbiter that is acceptable to both parties.
Each Community Pharmacy will have a unique ID number and returns received by Medicine Management
(Commissioning) from the CSO will be used to determine payments
Drug cost at tariff or list price as appropriate
Page 7 of 27
11.
Authorisation
Name of
Pharmacy
Agreed on behalf of the
Pharmacy
Agreed on behalf of the
NHS North of Tyne
_ _/ _ _/ 200_
_ _/ _ _/ 200_
Name
Position/Title
Signature
Date
By signing this agreement the Pharmacy and those trained pharmacist(s) will
comply with and work in accordance with the provisions of this SLA and the
attached Service Specification.
Name(s) of trained
Pharmacist(s)
RPSGB Registration
number
Date
_ _/ _ _/ 200_
_ _/ _ _/ 200_
_ _/ _ _/ 200_
_ _/ _ _/ 200_
12. Confidentiality
12.1
The Pharmacists and their staff must not disclose to any person other than a
person authorised by the NHS North of Tyne any information acquired by
them in connection with this Agreement.
12.2
Without prejudice to the generality of Clause 9.1, the Pharmacist and their
staff must not disclose to any person other than a person authorised by the
NHS North of Tyne any information acquired by them in connection with the
provision of the services hereunder which concerns:
 The NHS North of Tyne, its staff or procedures
 The identity of any client
 The medical condition of or the treatment received by any client.
Page 8 of 27
13
Eligibility
13.1
The pharmacy must employ one or more pharmacists or locum pharmacist
who have completed the NHS North of Tyne training programme and
authorised to undertake this specialised, enhanced sexual health service.
13.2
Authorisation is conditional on the following:
 Securing an honorary contract with Northumberland Care Trust
 Completion of the relevant CPPE training packs
 Annual attendance at the mandatory Northumberland Care Trust
Cardio-pulmonary and Resuscitation training session
 Successful completion of the Carlton Street practical initial training and
annual follow up training sessions
 Attendance at the evening theory training session
 Commitment to ensure continuous professional development
pertaining to EHC and LARC, e.g. attendance at a local fitters forum or
event
 Signing of the Service Level Agreement and EHC and LARC Patient
Group Directions
 CRB check within previous three years
13.3
The pharmacist is authorised to undertake the duties outlined in this service
level agreement in pharmacies registered as part of the scheme. Should the
pharmacist leave the employ of the premise owner and not be replaced
immediately by an accredited pharmacist, the Trust must be informed and
the pharmacy will no longer participate in the scheme, unless there are
other authorised pharmacists employed at the premises. The pharmacist
may be able to continue to participate in the scheme at other authorised
pharmacy premises in NHS North of Tyne only with the specific agreement
of the Trust.
13.4
A copy of the protocol must be kept freely available in the pharmacy and all
staff should be aware of its contents. If a locum is employed who is not
authorised to provide the service, clients must be made aware of alternative
locations where the service can be obtained.
13.5
To become authorised premises the pharmacy must have been identified by
the Trust as being in an area with a high level of teenage pregnancies. The
premises must have a consultation area. The consultation area must:
 Enable the pharmacist and client to sit down together
 Enable the conversation to be carried out at normal volume without
being overhead
 Be clearly signed as a private consultation area
 Be suitable for the administration and removal of the LARC, with
provision of suitable protective and cleaning materials
13.6
All serious clinical incidents must be reported to NCT using the appropriate
clinical incident form.
Page 9 of 27
13.7
14
15
Indemnity
14.1
The Pharmacy/pharmacist shall be liable for, and shall indemnify NHS North
of Tyne, its officers, employees and agents against any liability, loss, claim
or proceedings arising under statute or at common law in consequences
of this Agreement.
14.2
The Pharmacy shall maintain insurance of a minimum of £5 million in
respect of public liability and personal indemnity against any claims,
whatsoever which may arise out of the terms and conditions and
obligations of this Agreement and will at all times during the period of this
Agreement be a member of a recognized professional organisation. The
Trust will have the right to see documentary evidence of the foregoing
including policy renewal receipts prior to commencement of this agreement
or at any stage during the period of this Agreement. If the pharmacy fails to
maintain adequate insurance, or is no longer a member of an appropriate
professional organisation (for whatever reason), this Agreement may be
terminated by the Trust without prejudice to any other rights and
remedies available.
Tax Liabilities
15.1
16
It is hereby declared that it is the intention of the parties that the
Pharmacist/ Pharmacy shall have the status of a self-employed person and
shall be responsible for all Income Tax, VAT liabilities, and National
Insurance or similar contributions in respect of his fees and
reimbursements.
Termination of agreement
16.1
16.2
16.3
17
All pharmacists must have an up to date CRB Clearance which should be
renewed every 3 years. (The Trust will fund and facilitate the clearance
process).
Either party can terminate this agreement by giving one months’ notice in
writing, unless both parties agree a shorter period of notice.
This Agreement may be terminated by either party as provided by Clause
16.1 provided always that NHS North of Tyne may terminate or suspend
this Agreement forthwith if there are reasonable grounds for concern
including, but not limited to, malpractice, negligence or fraud on the part of
the pharmacy.
If events occur which could not have been reasonably foreseen and are of
such substance to affect the ability of either party to meet their obligations,
then joint negotiations will be undertaken to consider the future provision of
services or to terminate this Agreement without prejudice.
Standard of Service
17.1
The services hereunder shall be provided in accordance with this Agreement
and, except in emergencies, the pharmacy shall not deviate from this
Page 10 of 27
agreement without the prior written consent of the NHS North of Tyne.
17.2
In addition to any more specific obligations imposed by the terms of this
Agreement it shall be the duty of the pharmacy to provide the services
hereunder to a standard, which is in all respects to the reasonable
satisfaction of the NHS North of Tyne. The standard and quality of service
will be of paramount importance to the NHS North of Tyne in managing this
Agreement.
17.3
Without prejudice to the Contractors obligations to meet all performance
requirements under the contract, the contractor must, in the provision of
the service meet the standards set out in “Standards for Better Health”
published by the Department of Health on 21 July & available on the DH
website (gateway reference 3528). The contractor shall comply with all
relevant legislation (and directions there under) and have regard to all
relevant guidance issued by the PCT, Strategic Health Authority or the
Secretary of State.
18
Transfer and sub-contracting
18.1
Neither party may assign the whole nor any part of this Agreement, save
that the NHS North of Tyne may assign (where not otherwise facilitated
under operation of law) where the NHS North of Tyne or part is taken over
by another health service body.
18.2
The pharmacy must not sub-contract the supply of services hereunder
without the NHS North of Tyne’s previous consent in writing.
19
Staff
19.1
20
The pharmacy shall in respect of all persons employed or seeking to be
employed by the pharmacy (whether in and about the provision of the
services hereunder or otherwise) comply with each and every provision of
law including those, which prohibit discrimination in relation to employment
on the grounds of sex, colour, race, ethnic or national origin or religion.
Audit
20.1
The pharmacy must allow access by NHS North of Tyne’s internal and/or
other nominated auditors to all or any papers relating to this Agreement for
the purposes of audit.
20.2
21
The pharmacy must fully co-operate to carry out service evaluation audits
as required.
Data Protection
21.1
The pharmacy must protect personal data in accordance with provisions and
the principles of the Data Protection Act 1998 and must ensure the
reliability of their staff that have access to the data.
Page 11 of 27
21.2
All pharmacists are required to maintain the confidentiality of client data in
line with Caldicott guidance3. Pharmacists are reminded of their obligation
within the code of ethics, in particular the maintenance of confidentiality4
21.3
The pharmacy must indemnify NHS North of Tyne against all claims and
proceedings and/or liability, loss, costs and expenses incurred in connection
therewith made or brought by any person in respect of any loss, damage or
distress caused to that person by the disclosure of any personal data by the
pharmacy, its staff or agents.
21.4
‘Personal Data’ has the same meaning as in the Data Protection Act 1998,
Section 1 (1).
21.5
Clients records should be maintained in line with record management policy5
21.6
Data transfer via fax must comply with the Transfer of Personal Information
Policy6.
22
Complaints
21.1
The pharmacy will be required to have a system for the handling of
complaints. All complaints received must be fed back in a timely fashion to
the NHS North of Tyne complaints manager.
23
Publicity
21.1
All media queries regarding to the EHC service should be handled with the
knowledge of the NHS North of Tyne’s public relations officer and referred to
Strategic Manager Sexual Health.
Please complete and return the original copy of this agreement to the address
below to be countersigned by the Trust; a facsimile copy will be returned to you
for your records. Medicine Management
NHS North of Tyne
Bevan House
1 Esh Plaza
Sir Bobby Robson Way
Great Park
Newcastle
NE13 9BA
NoT IG&T07 - Information governance policy and strategy V1 — NHS North of Tyne
Rpsgb.org: Code of Ethics for Pharmacists and Pharmacy Technicians
5
NoT IG&T01 - Records management policy and strategy V1 — NHS North of Tyne
6
NoT IG&T08 - Transfer of personal information policy V1 — NHS North of Tyne
3
4
Page 12 of 27
Appendix I
LARC MONTHLY AUDIT SHEET: Pharmacy Name: …………………….
Completed by: …………………… RPSGB Reg. No: ………
Client’s post code
Age
Date seen
Date submitted: _ _/ _ _/ 200_
Named
pharmacist
Including RPSGB Reg.
No.
1
_ _/ _ _/ 200_
2
_ _/ _ _/ 200_
3
_ _/ _ _/ 200_
4
_ _/ _ _/ 200_
5
_ _/ _ _/ 200_
6
_ _/ _ _/ 200_
7
_ _/ _ _/ 200_
8
_ _/ _ _/ 200_
9
_ _/ _ _/ 200_
10
_ _/ _ _/ 200_
Implanon®
inserted or DepotProvera®
initiated/
repeated (please state)
Chlamydia
Screening
Y/N
Positive
result
treatment &
Partner
notification
completed
NB. Claims for issue of Chlamydia screening test can only be made once and should appear on either this form or the
Summary record of EHC
consultation
form, see
Appendix
Working
on behalf of Newcastle
and North
Tyneside 3
Primary Care Trusts and Northumberland Care Trust
Page 13 of 27
Total
Cost
Appendix II
REFERRAL PROFORMA
CLIENT DETAILS
Name: ……………………………………….
Address: ………………………………………
DOB/AGE: …………………….
LMP ……………………..
GP: …………………………………
Pharmacy contact date: dd/mm/yyyy
EHC provided: Y/N
Reason for referral: ……………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
Referrer (PHARMACY DETAILS): …. ………………………………………………..
Client Preferred Contact Details
Preferred method please circle: Mobile/ landline/ letter/text
Contact details please provide: mobile/ telephone number or address for
correspondence: …………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
I have informed the client that they will be contacted by a member of the Sexual Health
Service within 1 week of referral.
Signed: …………………………………………
RPSGB Reg. No.: ………...
Please return by Fax to chosen clinic for follow up appointment:
NORTHUMBERLAND
Carlton Street Clinic
Blyth
Northumberland
NE24 2DT
Tel: 01670 543130
FAX: 01670 543132
NORTH TYNESIDE
NEWCASTLE
1 – 1 Centre
New Croft House
Brenkley Avenue
Market Street
Shiremoor
Newcastle
NE27 0PK
NE1 6ND
Tel: 0191 2970441
Tel: 0191 229 2999
FAX: 0191 2979857
FAX:0191 229 29769
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 14 of 27
Summary record of EHC consultations
Appendix III
Month: _____________
Pharmacy stamp/ address:
Pharmacist Name: ___________________
Date
Staff
Initials
Postcode
Age
Reason
(1)
Test
(2)
Supply
(3)
Dose
(4)
Referral
(5)
Total number of consultations:
Total number of Tablets:
Prior
(6)
Chlamydia
test issued
Condom Pack
Supplied
(tick)
Time
(7)
Total number of referrals:
Total time taken (minutes):
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 15 of 27
Source
(8)
Ethnicity
(9)
Key:
(1) Reason for client’s concern:
U = unprotected, C = contraceptive failure, M = missed pill, O = other
(2) Was a pregnancy test given:
P = pre-supply, A = post-supply, B = both
(3) Was POEC supplied:
Y = yes, N = no
(4) What dose was supplied:
S = standard dose, A = additional dose after 12 hours, R = repeat dose after vomiting
(5) Was the clients referred:
N = no, G = GP practice, H = specialist service, P = another pharmacy, S = school health
adviser
(6) Is the client known to have requested POEC in the previous three months:
Y = yes, 0 = unknown, N = no
(7) Time taken: enter the time, in minutes taken to complete the consultation and
associated records
(8) Source: where the client heard about the scheme:
M = Media (Newspaper, Radio, Flyer)
P = Poster
R = Recommendation from a friend/ relative
H = Recommendation from a health professional (GP, Nurse, Health Visitor, Sexual Health
Clinic)
O = Other
(9) Ethnicity Codes:
White
A British
B Irish
C Any other white background
Mixed
D White and Black Caribbean
E White and Black African
F White and Asian
G Any other mixed background
Asian or Asian British
H Indian
J Pakistani
K Bangladeshi
L Any other Asian background
Black or Black British
M Caribbean
N African
P Any other Black background
Other ethnic categories
R Chinese
S Ant other ethnic category
Not Stated
Z Not Stated
Form to be returned with the monthly Invoice to:
Chelsea Harrison, Medicines Management, NHS North of Tyne, Bevan House, 1
Esh Plaza, Sir Bobby Robson Way, Great Park, Newcastle upon Tyne, NE13 9BA.
Form to be returned no later than the 5th of the month.
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 16 of 27
Form IV
Record of consultation for Plan B (POEC)
(Levonelle 1500®)
Pharmacy stamp
Client’s name: …………………………………………
Date of consultation: dd/mm/20yy
Age / (DOB): XX yrs (dd/mm/yyyy) Ref no: …..
Post code: ……………… Ethnicity…………………
Client’s history
Date of first day of last menstrual cycle: …………………….. therefore day ………of
cycle
Has the client had Levonelle 1500® or Levonelle One Step® since last period?
………..
Reason for request: Unprotected…….
Failure……
Missed pill……
Other…….
Criteria for inclusion
Yes
No
N/A
3rd
Is the client beyond the
day of a spontaneous
menstrual cycle?
Has the client missed her contraceptive pill?
Advice given if missed contraceptive pill?
Client has received POEC but has vomited within two
hours (provided UPSI still within 120 hour period)
All options for emergency contraception including copper
IUD discussed?
Clients prefers hormonal method
Criteria for exclusion (referral)
Did UPSI occur between 72 and
120 hours ago?
Has the client used Levonelle
1500 within this cycle?
Is the client pregnant or likely
to be pregnant?
If the client is not using
hormonal contraception was her
last period more than 4 weeks
ago?
If the client is not using
hormonal contraception was her
period abnormal, different
Yes
No
Notes
If ‘yes’ discuss copper IUD as first
choice but can dispense Levonelle
1500 if within 120 hours
If ‘yes’ – discuss more effective
contraceptive methods but further
Levonelle 1500 can be given
If ‘yes’ pregnancy test should be
performed. If refused – refer
If ‘yes’ perform a pregnancy test or
refer. Levonelle 1500 may be given if
you are reasonably sure she is not
pregnant.
If ‘yes’ perform a pregnancy test or
refer. Levonelle 1500 may be given if
you are reasonably sure she is not
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 17 of 27
length or flow?
Does the client have breast
cancer?
Does the client have severe
liver disease?
Does the client have porphyria?
If under 16 years of age, is the
client deemed competent?
pregnant.
If ‘yes’ – refer
If ‘yes’ – refer
If ‘yes’ – refer
If ‘no’ – refer
Additional information: does the client require an increased dose (two
tablets of Levonelle 1500 taken as a single dose e.g. malabsorption
disease, concurrent liver enzyme inducer? …....... Reason:
………………………………….
Counselling
Mode of action discussed
Failure rate discussed
Side effects discussed
Possible effects on foetus discussed
Dose taken on premises
Time of second dose agreed (if increased dose required)
Follow-up discussed
Future contraception discussed
Yes
No
Other relevant information:
Where the client heard about the scheme: …………………………………………………..
Action taken:
If supply made: Batch number:
Expiry date: dd/mm/yyyy
Referral to:
Advice given:
The above information is correct to the best of my knowledge. I have been
counselled on the use of emergency contraception and understand the
advice given to me by the pharmacist.
Client’s signature: _____________________ Date: dd/mm/yyyy
The action specified was based on the information provided to me by the
clients, which, to the best of my knowledge, is correct.
Pharmacist’s signature:__________________Date: dd/mm/yyyy
Time taken to complete consultation ……………. minutes.
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 18 of 27
Appendix V
Assessing competence for clients according to Fraser guidelines
A young person’s competence to understand their treatment must be
assessed. The assessment must be fully documented and should include
an assessment of the client’s maturity. The discussion with the client
should explore the following issues at each consultation:
Assessment of competence
Understanding of advice given
Yes
No
Encouraged to involve parents
The effect on the physical or mental health of the
young person if advice / treatment is withheld
Action is in the best interest of the young person
Vulnerability/ Safeguarding Assessment Under 16’s
Who is the young person accompanied by
Age of partner
Was sex consensual
Suggestions of “grooming” or “abuse”
Gifts/bribery
Substance/alcohol intake impedes
informed decision making?
Any other cause for concern
Pharmacist’s name: ___________________________(Block capitals)
Pharmacist’s signature_____________________ Date: dd/mm/yyyy
Client’s name :________________________________(Block capitals)
Client’s signature: _________________________ Date: dd/mm/yyyy
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 19 of 27
Record of consultation for long
acting reversible contraception (LARC) –
Implanon®/ Depo-Provera®
Appendix VI
Pharmacy stamp
Client’s name
Date of
consultation
dd/mm/20yy
Age / (DOB)
XX yrs (dd/mm/yyyy)
Ethnicity
Post code
Ref no
Client’s history
Date of first day of last menstrual cycle
therefore day _____ of cycle
Reason for request
How did client become aware
of the service?
New method of contraception
Y/N
Alternate method of contraception
Y/N
Self referral for EHC
Y/N
Following local awareness campaign
Y/N
Word of mouth from friend
Y/N
Criteria for inclusion
Has the client chosen to have LARC after receiving counselling
on different forms or contraception?
Is the client between the 1st and 5th day of menstrual bleeding?
If beyond the 5th day of menstrual bleeding provide pre-emptive
Levonelle 1500® or condoms via C-Card service.
Is client changing from an alternate hormonal contraceptive?
If yes what was it?
Combined hormonal contraceptive:
oral contraceptive/ vaginal ring, trans-dermal patch?
or, progestogen only method,
mini-pill /injectable /different implant/ intrauterine system?
Has the client have a personal or family history of DVT?
Yes
Does the client have a history of side effects with oestrogen
therapy?
Is oestrogen contra-indicated in the client
Is the client diabetic?
Has the client experienced compliance difficulties with other
forms of contraception?
Does the client smoke?
If yes do they smoke > 20 cigarettes or equivalent per day?
If Depo-Provera® is being considered have all other methods
have been discussed with the patient and considered to be
unsuitable or unacceptable?
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 20 of 27
No
N/A
Criteria for exclusion (referral)
Yes
__/__
What is the client’s current BP?
mmHg
Is the client pregnant or likely to be
pregnant?
Has the client experienced any
hypersensitivity reactions to the active
substance or to any of its excipients?
Does the client exhibit signs of pelvic
inflammatory disease?
Notes
No
If ‘BP ≥ 160/100 mmHg refer to GP, if client
agrees or to CASH.
If ‘yes’ pregnancy test should be performed.
If refused – refer
If ‘yes’ – refer
If ‘yes’ – refer
If the patient takes warfarin, refer.
Does the client take any other medication?
If the patient takes an enzyme inducing drug
Implanon® is ineffective, consider DepoProvera® or refer.
Does the client have a history of hepatocellular jaundice?
Does the client have porphyria?
Does the client have a history of arterial or
heart disease or migraine with aura?
Does the client have breast cancer?
If the client is diabetic do they have
diabetic nephropathy/ retinopathy/
neuropathy?
Does the client have undiagnosed vaginal
bleeding?
Does the client have a recent history of
gestational trophoblastic neoplasia e.g.
hydatidiform mole?
Does the client have a recent history of
pruritis of pregnancy?
Has the client requested to see a doctor?
If less than 16 years of age, is the client
deemed competent?
If ‘yes’ – refer
If ‘yes’ – refer
If ‘yes’ – refer
If ‘yes’ – refer
If ‘yes’ – refer
If ‘yes’ – refer
If ‘yes’ – refer
If ‘yes’ – refer
If ‘yes’ – refer
If ‘no’ – refer
Counselling
Yes
Mode of action discussed
Failure rate discussed
Side effects discussed
Client to return for insertion/ injection
Date and time for follow up 3 monthly doses agreed (if Depo-Provera®
chosen)
Follow-up discussed, and appointment made as appropriate.
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 21 of 27
No
Other relevant information:
If supply made:
Implanon®/ Depo-Povera®
Batch number:
Date & Time
(delete as applicable)
Expiry date: mm/yyyy
insertion/injection:
Apply Implanon®
label here
_ _ :_ _hrs dd/mm/yyyy
Referral to (including date):
Advice given/ site of insertion or injection/ adverse reactions/ anaphylaxis
treatment administered (give full details) :
Details of anaesthetic used(give full details):
Batch number:
Expiry date: mm/yyyy
For Implanon® verify the presence of the implant upon completion of the
procedure for insertion (delete as applicable)
Y
N
For Depo-Povera® confirm decision follows a discussion on the full range
of alternate contraceptive options, including their risks and benefits
Y
N
The above information is correct to the best of my knowledge. I have been counselled on the
use of emergency contraception and understand the advice given to me by the pharmacist.
Client’s signature: __________________
Date: dd/mm/yyyy
The action specified was based on the information provided to me by the clients, which, to
the best of my knowledge, is correct.
Pharmacist’s signature:_______________
Date: dd/mm/yyyy
Time taken to complete initial consultation ……………. minutes.
Follow up visit
1st follow up
– 12 weeks
2
nd
follow up
- 24 weeks
3
rd
follow up
– 36 weeks
4 follow up
– 48 weeks
5th follow up
– 60 weeks
6 follow up
– 72 weeks
th
th
7 follow up
- 84 weeks
8th follow up
– 96 weeks
th
Date and time
of follow up DepoProvera®
Pharmacist’s
signature
Client’s signature
9th follow up – 108 weeks
10th follow up – 120 weeks
11th follow up – 132 weeks
12th follow up – 144 weeks
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 22 of 27
Appendix VII
Partner Notification Form
Treatment Site:
Treatment Date:
Index Client’s Name:
Gender:
D.O.B:
CH No:
M
/ F
Number of Partners in last 6 months:
Please obtain details of all partners within the last 6 months. If no
partners within the last 6 months, please obtain details of the most recent
partner
Partner No:
Name:
Gender:
D.O.B:
Phone:
M
/ F
Address:
Postcode:
PSI: Always
LSI:
Sometimes
Partner Referral Method:
Never
Client
If ‘Provider’ Indicate method of Contact:
Length of relationship:
Provider
Telephone
Non-contactable
Letter
If ‘Client’ please tick one of the following:
Attended with client
Client will inform
Contact slip issued
Partner already informed
Partner already treated
If already treated, Location: ______________________
Partner No:
Name:
Gender:
D.O.B:
Phone:
M
/ F
Address:
Postcode:
PSI: Always
LSI:
Sometimes
Partner Referral Method:
Never
Client
Length of relationship:
Provider
Non-contactable
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 23 of 27
If ‘Provider’ Indicate method of Contact:
Telephone
Letter
If ‘Client’ please tick one of the following:
Attended with client
Client will inform
Contact slip issued
Partner already informed
Partner already treated
If already treated, Location: ______________________
Index Client’s Name:
Gender:
D.O.B:
CH No:
M
/ F
M
/ F
Partner No:
Name:
Gender:
D.O.B:
Phone:
Address:
Postcode:
PSI: Always
LSI:
Sometimes
Partner Referral Method:
Never
Client
If ‘Provider’ Indicate method of Contact:
Length of relationship:
Provider
Telephone
Non-contactable
Letter
If ‘Client’ please tick one of the following:
Attended with client
Client will inform
Contact slip issued
Partner already informed
Partner already treated
If already treated, Location: ______________________
Partner No:
Name:
Gender:
D.O.B:
Phone:
M
/ F
Address:
Postcode:
PSI: Always
LSI:
Sometimes
Partner Referral Method:
Never
Client
If ‘Provider’ Indicate method of Contact:
Length of relationship:
Provider
Telephone
Non-contactable
Letter
If ‘Client’ please tick one of the following:
Attended with client
Client will inform
Contact slip issued
Partner already informed
Partner already treated
If already treated, Location: ______________________
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 24 of 27
Appendix VIII
Northumberland Tyne and Wear Chlamydia Screening Programme
Pharmacy Treatment Sheet
Date/ Time:……………..…… Treatment venue:……………………………….……
Name:………………........................................... CH no: ………..…….…………..
Please tick: Contact client
IP No: ........................................
Index client
D.O.B:…...………….. Age: ……...
Under 16 Assessing competence for clients according to Fraser
guidelines completed
YES/NO
Address:………………………………..………………………………………………..
……………….……………………………………………………………………..….
Post Code:…………………Telephone…………..……………….…………………..
Previous STi’s
Diagnosis : Chlamydia – Discuss Previous Test yes/no Result Neg/Pos
Symptoms: Discharge* IMB* PCB* BTB* Pelvic pain/dyspareunia* Scrotal Pain*
Dysuria* Conjunctivitis and /or joint pain Fever* Feeling unwell* Asymptomatic*
Other:
Referred to GUM/GP
Relevant past medical history:
Current medication:
Referral letter Yes/No
LMP:
Menstrual cycle
Present contraception
Any risk of pregnancy Yes/no
Breast feeding
Yes/no
PT
neg. / pos./ not indicated
Details:
Allergies:
Drug Use discussed: Yes / No
Drugs used:
LSI:
Casual/ Regular Partner (Current/Ex)
Type:
Oral Vaginal Anal (advise risks)
Sexual orientation: Heterosexual, Gay, Lesbian, Bi-Sexual, Transsexual
Condom use: always / occasionally / never C-card
Aware of C-Card Scheme? Yes/No
Safe sex discussed? Yes/No
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Page 25 of 27
Treatment Given
Date
Prescription
Brand or
Manufacturer
Batch no & expiry
Signature
Azithromycin po
BN:
1gm stat dose
Verbal
consent
obtained
Treatment
Supervised
(sign to confirm &
date)
Y/N
Exp:
Doxycycline po
BN:
100mg bd x 7 days
Y/N
N/A
Exp:
Erythromycin
stearate po 500mg
BN:
bd x 14 days
Exp:
Y/N
If Pregnant discuss treatment options: Yes/No
Partner Notification (complete partner notification form/s)
Tick Discussed
Box
Advised to attend GUM for full screening
Contact details given for GUM/ Sexual Health Services
Possibly COC interaction & 7–Day rule
Doxycycline / Azithromycin - Photosensitivity
Erythromycin - Need for “Test of Cure” in 5 weeks
Discuss common/ rare side effects. To contact GP/NHS direct if concerned.
Vomiting within next 3 hours, advised to contact pharmacy for retreatment
Discuss alcohol intake while on treatment
Info leaflet given - Chlamydia FPA / CSO*/antibiotic Pt. info.
Condoms given and advised no sex/ sexual contact while on treatment and next
7 days
Advised re-testing after every partner change or anytime if risk of re-infection
Given post treatment information sheet
Client Advised they will be contacted by CSP Health Advisor for compliance
Outcome
Compliant / Non-compliant / Non-contactable*
Signature / Name……………………………………………………………………
Date: ……………………....……………..…
Case closed to file:
Time: ………………………
Yes / No
Please Fax to Central Office 0191 229 2982
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 26 of 27
Appendix IX Care Pathway for provision of specialised, enhanced sexual health services via community pharmacies
Client makes
request for
EHC post UPSI
Client makes
request for
LARC
How old is the ♀?
Microbiology confirmed
positive Chlamydia result
CSO give Clients:
N
≥ 16 yrs
Y
Is the clients deemed competent?
(According to Fraser guidelines)
- CH number
- Location of pharmacies
in scheme
- Contact details for
pharmacy and opening
times
Clients contacted by CSO who communicate
to clients via chosen method. Health advisor
provides treatment options
Y
N
Chlamydia
screening kit issued
& advice for
completion given
Does clients meet
PGD criteria for
inclusion?
Direct referral to CaSH for
alternative emergency
contraception
Clients requests treatment via
pharmacy
Clients fails to
attend pharmacy
within one week
of positive result
Y
N
CSO contact pharmacy
and informed
Counselling
completed
EHC provided
Pharmacy
informs CSO
Clients attends pharmacy for
treatment, to be treated
according to PGD
Future contraception
discussed, and LARC
offered
Signpost/refer
to clients’s GP
≤ 19 yrs
N
Y
Offer of LARC
accepted
Direct referral to
CaSH for
alternative
preferred
contraception
i.e. coil or O/C
Fax all
completed
paperwork
to CSO
Provide
condoms and
consider
provision of preemptive EHC
Y
N
At time of
administration
is clients’s BP
ok?
Y
N
Treatment given in
accordance with PGD
& paperwork
completed
N
Does clients meet
PGD criteria for
inclusion?
Y
Undertake
administration of
LARC at mutually
convenient time
N
Y
Is LARC to be
administered between
days 1 – 5 of
menstrual cycle?
First line of
Partner
Notification
completed
Partner Notification follow up and
compliance check as agreed with
clients via CSO Health advisor
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Page 27 of 27
Attendance
follow up by
CSO
Does clients meet
PGD criteria for
inclusion?
Direct referral
to CaSH for
follow up
Offer written
information on
Chlamydia aetiology
& discuss relevant
health promotion and
potential referral to
CaSH for GUM
appointment