Elsevier

Social Science & Medicine

Volume 57, Issue 12, December 2003, Pages 2367-2378
Social Science & Medicine

Supplying emergency contraception via community pharmacies in the UK: reflections on the experiences of users and providers

https://doi.org/10.1016/S0277-9536(03)00129-1Get rights and content

Abstract

This paper discusses findings from an evaluation of a scheme to provide free emergency hormonal contraception (EHC) via community pharmacies in the North-West of England. Drawing on interview data with pharmacists taking part in the scheme and focus groups with users, we tentatively suggest that the scheme was largely well received. The benefits of the service, cited by both pharmacists and users, included enhanced access to EHC, at times when it was needed, and at no cost to the user. In particular, users noted a welcome absence of judgmental attitudes when accessing the service. Pharmacists too were positive about the service, not least because they believed that it conferred enhanced professional status. However, both users and pharmacists had a number of major concerns about the schemes, centring on the potential for misuse, changes in contraceptive behaviour and the impact on sexually transmitted infections. We conclude that more research is needed to explore these issues.

Introduction

Reviewing the history of contraceptive technologies, Ziebland (1999) points out that “birth control has only recently won a guarded respectability in developed countries and there remain issues around provision and education which are contested, among social commentators, government agencies, educationalists and the medical profession” (1999, p. 1410). Emergency hormonal contraception (EHC) has a similarly troubled history and has been described as occupying an anomalous position within the family planning repertoire, because of its use after sexual intercourse (Ziebland, 1999). Although there is considerable international evidence that provision of EHC from general practitioners (GPs) and other providers does not meet the needs of women (Ellertson, Shiochet, Blanchard, & Trussell, 2000), the many calls to expand access to EHC through community pharmacies have, until recently, met with inaction in the UK (Drife, 1993; Glasier (1993), Glasier (1997)).

In 1999, the emergency hormonal contraceptive agent PC4 (replaced by the progestogen only product Levonelle-2, both manufactured by Schering Health Care) became available free of charge in 16 locally accredited community pharmacies in Manchester, Salford and Trafford Health Action Zone in the UK via a group prescribing protocol known as a Patient Group Direction. Pharmacists in Lambeth, Southwark and Lewisham Health Action Zone followed suit setting up similar schemes in early 2000 and provision of EHC based on this model has expanded within Manchester, Salford and Trafford and to others parts of the UK.

This paper describes some of the results of an evaluation of the pharmacy-based EHC schemes set up in Manchester, Salford and Trafford Health Action Zone (Anderson, Bissell, Sharma, & Sharma, 2001). We present interview data with pharmacists participating in the scheme and data from focus groups with women who obtained EHC via this means. We suggest that whilst pharmacy supply of EHC may have improved access to EHC, a number of issues arising from the unintended consequences of the schemes remain to be explored in more depth. Before presenting the findings from this study, we highlight variations in the provision of EHC internationally, the policy and professional background to the EHC scheme in Manchester, Salford and Trafford, the reaction to these schemes and the scope of health services and social science research in this area.

There is widespread agreement that modern forms of EHC have a good safety profile, are easy to use and are effective in reducing the incidence of unwanted pregnancies after unprotected sex (World Health Organization, 2002; Trussell, Rodriguez, & Ellertson, 1999). Within the developed world EHC has traditionally only been available from family doctors (GPs in the UK), gynaecologists, specialist family planning clinics and accident and emergency departments of hospitals. Research has indicated that there are barriers interfering with access to EHC. These include lack of knowledge amongst the general public and health care professionals, problems in access to those prescribing it, unwillingness of young women to request medication from their local physician and reluctance on the part of health professionals to provide this method of birth control (Young, McGowan, & Roberts, 1995; Smith et al., 1996; Graham, Green, & Glasier, 1996; Blanchard, 1998; Glasier & Baird, 1998; Webb, 1999). For example, EHC has been described as “the best kept secret in family planning” because of its relative marginality (and controversial status) amongst the pantheon of contraceptive methods (Delbanco, Mauldon, & Smith, 1997). These findings suggest that women may be deterred from using EHC and this may contribute to the level of teenage and unwanted pregnancies (Ellertson et al., 2000).

Given these problems, a number of international initiatives have been designed which allow a wider group of health care professionals to prescribe and dispense EHC. In some states in the US, nurse midwives and nurse practitioners have the authority to prescribe EHC, or may be able to prescribe under protocols (Blanchard, 1998). Within the UK, family planning nurses have been able to provide EHC under protocol (Kishen & Presho, 1996; Brittain, 1999). Community pharmacists in parts of Canada, the US and the UK are now able to supply EHC, although there are a number of differences between these programmes (Gardiner et al., 2001; Soon et al., 2002). In order to reduce barriers to EHC, deregulation from prescription only to pharmacy status has now been adopted in Albania, Belgium, Denmark, France, Norway, Portugal, South Africa, Sweden and the UK (Soon et al., 2002) and allows for pharmacy sales of EHC. This paper concentrates on the UK experience of setting up schemes to provide free access to EHC via Patient Group Direction (a joint prescribing protocol) set up in the UK during the late 1990s and early 2000.

Concern about the comparatively high rate of teenage and unwanted pregnancies in the UK rose sharply up the political agenda with the election of the Labour government in 1997 (Social Exclusion Unit Report, 1999). One way of addressing this was to provide access to EHC in the pharmacy. However, deregulation of EHC to pharmacy status (i.e. changing its status from prescription only to pharmacy status) is contingent on the manufacturers making an application for a change in the product license to the Medicines Control Agency (the statutory body responsible for licensing medicines in the UK). Given political anxiety about appearing to condone unprotected sex, Schering Health Care (the manufacturers of EHC agents in the UK) were unlikely to make such an application in the late 1990s, despite numerous calls to make EHC available via the pharmacy (Drife, 1993; Glasier (1993), Glasier (1997)).

At around this time, an influential government report called for the relaxation of prescribing arrangements so that community pharmacists (and other health professionals) become ‘dependent’ (now referred to as ‘supplementary’) prescribers (Department of Health, 2000). Pharmacists working strategically in Health Authorities in England, seized on this as a means by which to provide EHC through community pharmacies. Another impetus to the development of EHC schemes came from the setting up of Health Action Zones (statutory bodies set up by the government to address inequalities in health) in certain economically deprived areas of the UK. Pharmacists strategically linked with the new HAZs saw the potential for developing the role of the pharmacist in relation to the provision of EHC. The policy freedoms available to HAZs allowed Manchester, Salford and Trafford Health Action Zone to implement local schemes providing access to EHC via community pharmacies (O’Brien and Gray, 2000). The scheme uses locally agreed patient group directions (PGD). PGDs are group prescribing protocols which provide the legal authority for (suitably trained and accredited) pharmacists to supply a prescription only medicine to requesting clients. As developed in Manchester, Salford and Trafford, the EHC scheme requires participating pharmacists to undergo an accreditation exercise which involves a training enhancement programme to equip them with clinical and communication skills appropriate to supplying EHC. A Delphi consultation was conducted to identify those pharmacists who were interested in taking part in the scheme: a group were then selected to take part on the basis of geographical spread and access (O’Brien and Gray, 2000). Training in relevant clinical skills was provided by local family planning doctors and local agencies involved in the supply of contraceptive services. This was supplemented by scenario-based communication skills training using women posing as clients in order to simulate real life consultations. After satisfactorily fulfilling the training programme, accredited pharmacists are then permitted to supply EHC to requesting users, free of charge, on completion of a consultation with requesting users. Pharmacists use the PGD protocol to guide their decision about the appropriateness of supply of EHC. In cases where they are unsure about whether to supply, clinical back-up exists through family planning doctors based in the local area who can be called upon to guide decisions. The service is confidential and anonymous, although the post-code of users is asked for in order to geographically track requests. Pharmacists conduct consultations with clients in a private area of the pharmacy.

From their outset, pharmacy-based EHC services were designed as sexual health services, rather than solely as outlets for the supply of EHC. Thus, pharmacists elicit and record the reasons for requiring EHC, provide information on contraception, sexually transmitted infections and the side effect profile of EHC. Under the terms of the protocol, EHC can be supplied to girls under the legal age of sexual consent (16 in the UK), alongside the provision to refuse to supply and to refer the client to other agencies where appropriate (O’ Brien and Gray, 2000). Pharmacists or the companies participating pharmacists work for, receive a payment of £10 per consultation.

Subsequent to setting up PGD schemes in the UK, EHC (Levonelle-2) was deregulated from a prescription-only medicine to a pharmacy-only medicine in January 2001. EHC is now available in all community pharmacies (where the pharmacists agrees to supply it) from January 2001 at a price of £19.99 (now £24.99) and the two means of supply co-exist in pharmacies which operate PGD schemes. The key differences between the two means of supply is that under the PGD schemes, EHC is supplied without charge to the user, and can be supplied to clients aged under 16, where the pharmacist deems supply is appropriate.

The decision to deploy EHC from community pharmacies in the UK has provoked considerable debate in the media (Seston, 2001). Despite guidance from the Royal College of Obstetricians and Gynaecologists that anxieties about “repeated use of emergency pill is not justified because the hormonal dose…is equivalent to no more than seven pills of a low dose combined pill” (Kubba, 1995), some responses to the pharmacy-based schemes have been hostile. Much of the national media coverage has focused on supply of EHC to girls aged under 16 and the undermining of ‘family values’ (Seston, 2001). Concern was expressed from the Prime Minister's office about the scheme, and for some time, the legal basis of the schemes was questioned (O’Brien and Gray, 2000). Some health professionals have subsequently questioned the appropriateness of EHC supply at ‘High Street’ locations and raised concerns about the potential impact of pharmacy supply on sexually transmitted infections (Stammers, 2001). Clearly, this is an issue which touched a nerve in many quarters.

Community pharmacy has experienced de-skilling over the second half of the 20th century as a result of the redundancy of its traditional compounding function, brought about by the development of original pack dispensing by the pharmaceutical industry (Anderson, 2001). With this, pharmacy lost one of the cornerstones of its professional legitimacy within the health care division of labour (Hibbert, Bissell, & Ward, 2002). As a result, the leadership of the profession has been actively seeking new roles and responsibilities in order to counter the charge that pharmacists are ‘over qualified and under utilised’ (Wardwell, 1979). The professional organisation (RPSGB) has been actively involved in a series of measures designed to modernise and re-professionalise pharmacy (Edmunds & Calnan, 2001). These include pharmacy in a new age (PIANA) which aims to ‘realise the potential of pharmacy’ given that they are considered to be a ‘massively under used resource’ in health care. Other pharmacy organisations such as the negotiating body for pharmacy, the Pharmaceutical Services Negotiating Committee (PSNC) and the National Pharmaceutical Association (NPA) have also been involved in attempts to raise public awareness of the under utilised skills of pharmacists. This work has taken place against a backdrop of sociological research which has raised questions about the professional status of pharmacy (Denzin & Mettlin, 1968) and attempts to engender professional closure around certain health related activities (Hibbert et al., 2002). In this context, the development of EHC schemes can be seen as a means of re-professionalisation and role enhancement for community pharmacy (Edmunds & Calnan, 2001), despite their controversial status.

Although there is a large social science literature on contraception (Lupton, 1994), EHC has only recently become a focus of enquiry for social scientists (Ziebland, 1999). In one study exploring GPs attitudes to the deregulation of EHC in the UK, Ziebland (1999) found that they were concerned that clients would miss out on a discussion of their long-term contraceptive needs or the risks of sexually transmitted infections. Another interview based study of GPs and pharmacists attitudes towards deregulating EHC to pharmacy status produced such anxiety that the authors suggested that underlying participants views were a set of assumptions about women's sexuality as “irresponsible, devious and chaotic” (Barrett & Harper, 2000). That the availability of contraception may not accord with the views of health professionals is highlighted by Hawkes's (1995) study of family planning nurses and doctors. Focusing on attitudes to birth control in general, she found that her respondents described ‘responsible’ and ‘irresponsible’ users of contraceptive services. They were also concerned that free supply of contraceptives would encourage promiscuous sexual behaviour. As Ellertson et al. (2000) note in a review of the international literature, judgmental responses towards EHC users has been a relatively common feature of health professionals’ attitudes.

However, most of the work above was conducted prior to the supply of EHC in community pharmacies in the UK and there are few published studies which have explored the attitudes and experiences of users and participants regarding such services. We move on now to describe the methods used in this study.

Section snippets

Methods and sample

In order to gather data on the views of pharmacists involved in the EHC scheme, depth interviews were chosen. Given the working practices of pharmacists, this was considered the most effective means of recruiting respondents whilst also allowing issues to be explored in depth (Mason, 1996). Twenty-four interviews took place, drawn from a total of 55 pharmacists participating in the scheme at the time of the evaluation. The sampling of interviewees attempted to provide a spread in terms of the

The views of participating pharmacists

Pharmacists were initially asked to tell us about their general views of participating in the EHC scheme. Almost all of those interviewed expressed initially positive views about the EHC scheme. Responses ranged from one pharmacist stating that she was ‘delighted’ to be involved, to others expressing the view that the scheme was a ‘good idea’ for users and for the pharmacy profession. Many believed that the scheme would help to reduce teenage and unwanted pregnancy. One pharmacist expressed a

Positive assessments of the EHC service

We began the focus groups with users, by asking participants to tell us what they thought the EHC scheme and to describe their experiences of accessing EHC in the pharmacy. Like the participating pharmacists, all users provided generally positive assessments of the service. The responses that were elicited included descriptions of the attitude of the pharmacist as ‘helpful’, noting that the scheme was ‘convenient’ and offered a speedy means by which to obtain EHC when it was needed. All thought

Discussion

International research reveals considerable disquiet on the part of users regarding their experiences of obtaining EHC from other providers (Ellertson et al., 2000). Whilst expressing caution about our small and possibly unrepresentative sample, it was clear that the users we spoke to felt comfortable requesting EHC from the pharmacy. Very few users referred to incidences whereby pharmacists were judgmental or critical in response to requests for EHC and most commented positively on their

Conclusions

The pharmacy-based EHC schemes described here were viewed positively as a way of enhancing access to EHC by both pharmacists and the small sample of users we spoke to. However, both groups clearly had major concerns about the schemes. There may be unintended or unwanted consequences of changes to the availability of EHC and in the absence of thorough going surveillance over supply, those using this service can effectively choose to use EHC in ways that they see fit, whatever the health

Acknowledgements

We would like to thank Manchester, Salford and Trafford Health Action Zone for funding this study and all the pharmacists and women who took part in the research. We would also like to thank the comments of the two anonymous referees and those of Dr. Nicola Gray who also commented on drafts of the paper.

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