Where do you stand on dispensing EHC?


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Emergency hormonal contraception (EHC) has been available in the UK for over 30 years, so why does its supply remain a contentious issue for many pharmacists, asks Saša Jankovic

The first prescription-only combined oestrogen-progestogen dedicated emergency hormonal contraception (EHC) – Schering PC4 (ethinylestradiol and norgestrel) – was approved in the UK in January 1984.

But it is still making headlines, decades later.

Boots was recently embroiled in a media storm for refusing to lower the price of EHC, despite a popular campaign to improve access to the medication in the UK.

The multiple then appeared to exacerbate the issue when its chief pharmacist Marc Donovan said the company would not want to be accused of ‘incentivising inappropriate use’ of EHC, prompting widespread outrage including a letter signed by more than 30 Labour MPs.

The health and beauty giant subsequently apologised for its ‘poor choice of words’. It also announced the roll-out of the generic version of levonorgestrel in around 40 stores for the reduced price of £15.99 (compared to the previous cost of £26.75, but still more expensive than Superdrug and Tesco, which charge £13.49 and £13.50 for the drug, respectively) alongside the more expensive, branded version Levonelle and HRA Pharma’s ellaOne (ulipristal acetate).

Focusing its praise on Boots’s competitors, the British Pregnancy Advisory Service (BPAS) responded to the climbdown, with its director of external affairs Clare Murphy saying: ‘It’s brilliant to see Superdrug and Tesco leading the way on this issue, providing women with an affordable product that they can use when their regular method lets them down.

‘Improving women’s access to emergency contraception – including by reducing the price – boosts women’s physical and mental wellbeing, enabling them to avoid an unwanted pregnancy, which can pose a serious risk to their health.’

But not all healthcare professionals would agree that dispensing EHC is a morally defensible choice. Dr Peter Saunders, chief executive of the Christian Medical Fellowship, and formerly a general surgeon, responded to Boots’s climbdown, saying it was: ‘regrettable that Boots has capitulated in the face of political pressure and failed to support its chief UK pharmacist in his legitimate concerns over incentivising the inappropriate use of emergency contraception’.

He adds: ‘It is settled science that making so-called emergency contraception more easily available does not reduce pregnancy rates in a population and actually raises rates of sexually transmitted diseases.’

Indeed, there is a lack of evidence that EHC reduces pregnancy rates. However, if taken correctly, both ulipristal acetate and levonorgestrel are highly effective, with a 1.3% and 2.2% chance of failing to prevent pregnancy, according to a 2010 study.

There do not appear to be exact figures for how many pharmacists offer EHC in the UK, but the drugs are available free in some areas as part of locally commissioned sexual health services.

‘I will never provide EHC’

So why do some pharmacists object to dispensing EHC? For many, it comes down to ethical or religious beliefs that life begins at conception and that embryos are already endowed with personhood. Because the mechanism of action of the available EHC medication is likely to include the hindering of the implanting of the fertilised egg in the uterus, they see this as violating the sanctity of life.

It is not just women seeking EHC who have choices. Andrew Paxton, a superintendent pharmacist in Lancashire, says: ‘As a Catholic, I respect all human life from conception and will never provide EHC on my own account’, and he is not alone in his thinking.

In 1994, while working for the Co-op pharmacy in Brighton and Hove, Caroline Hubert researched embryonic human development. She says: ‘I realised that EHC, and indeed all oral contraceptives, have the potential to act in such a way that they can end a new human life. It is my personal conviction that all human beings deserve the right to life from the moment of their conception to their natural death.

‘In conscience, and out of respect for human life, I could never supply anything that would threaten the life of another – whether that person is born or pre-born, even at the pre-implantive stage. For this reason, I found myself unable to provide anything such as EHC or related chemicals as I had to recognise that there were potentially two people before me and that the use of EHC could or would cause the death of one.’

Ms Hubert says she found that the most acceptable way of dealing with the situation was ‘to simply say “I’m sorry but I don’t provide EHC” and to tell the patient that they could access it elsewhere – or from a colleague.

This outcome is echoed by fellow pharmacist Rosemary Baker, who says: ‘I always treated (EHC) requests with dignity and respect and explained why I felt I could not make the supply. I always received respect in response and never remember anyone leaving the premises upset.’

Ms Baker registered as a pharmacist in 1963 and retired in December 2015. She spent 10 years in industry in her early career before combining community pharmacy work with a lectureship in pharmacy practice at Liverpool John Moores University, which included pharmacy law and ethics.

She says the ‘belief that life begins when the sperm penetrates the egg is a perfectly reasonable, science-based belief and is worthy of respect. To be party to supplying a drug that will prevent that life from surviving is, to me, morally wrong.’

So what course of action should pharmacists take if they feel uncomfortable dispensing EHC? Those looking to the General Pharmaceutical Council (GPhC) for a regulatory framework for the supply of EHC will find there are guidelines, rather than rules, when it comes to the intersection of religion, personal values and beliefs in pharmacy.

In its guidance on religion, personal values and beliefs, updated in June 2017, the regulator states that ‘pharmacy professionals have the right to practise in line with their religion, personal values or beliefs as long as they act in accordance with equalities and human rights law and make sure that person-centred care is not compromised’.

While there is no explicit reference to the refusal to supply EHC, the guidance stresses that pharmacy professionals must think ‘in advance about the areas of their practice that may be affected and make the necessary arrangements so they do not find themselves in the position where a person’s care could be compromised.

This might include considering any time limits or other barriers to accessing medicines or other services, as well as any adverse impact on the person’.

As time is of the essence with EHC supply, the GPhC’s further clarification is important: ‘We want to be clear that referral to another health professional may be an appropriate option, and this can include handover to another pharmacist at the same, or another, pharmacy or service provider’.

Referrals

However, community pharmacist Deborah Evans – managing director of pharmacy training and consultancy company Pharmacy Complete, which works with HRA Pharma, manufacturer of ellaOne – warns that a referral ‘may not be appropriate in every situation.

‘For example, a service might not be accessible or readily available elsewhere, or the person’s vulnerability might mean
a referral would effectively obstruct timely access to the service,’ she says.

‘Again,’ she adds, ‘pharmacy professionals should use their professional judgment to decide what is appropriate in individual cases and keep a record of these decisions, including any discussions with the patient.’

Effects of refusal

Because EHC products are most effective when taken as soon as possible after unprotected intercourse or contraceptive failure, pregnancy is not the only possible consequence of refusing EHC supply, as Ms Evans explains: ‘Thinking that you might get pregnant can be very distressing for a woman and refusal will further add to this anxiety.

‘Some women may not have adequate time, money or access to transport to go to another pharmacy. Pharmacists also need to consider the professional consequences of an EHC refusal if the woman becomes pregnant.’

With that in mind, it is worth noting that the GPhC’s guidance also includes the requirement that pharmacy professionals should not ‘knowingly put themselves in a position where they are unwilling to deliver or arrange timely care for a person’, with the strongly worded suggestion that: ‘They should consider whether this means that certain professional roles will not be appropriate for them’.

Whether providing EHC or refusing to dispense it, pharmacy professionals are required by the guidance to be sensitive in the way they communicate with people and ‘not imply or express disapproval or judgment’.

In practice, Ms Evans says the best way to ensure a woman feels supported and not judged when coming in for advice on EHC is by ‘remaining objective yet understanding, and offering her the opportunity to speak privately in the consultation room if she wishes… remaining neutral and supportive of whatever decision she chooses to make’.

Pharmacists should also ensure the entire team is trained to treat patients with respect and sensitivity and to make sure women understand all the choices available to them as per the latest guidance from the Faculty of Sexual and Reproductive Healthcare.

Pro patient choice

Local pharmaceutical committee member Thorrun Govind, pharmacist at Sykes Chemist, a chain of independent pharmacies in Bolton, and resident pharmacist at BBC Radio Lancashire, says she has often had women referred to her by other pharmacists in the area that are unwilling to supply EHC.

However, Ms Govind believes that pharmacists must be willing to put their personal beliefs to one side for the sake of the patient.

‘Making the patient our first concern means we might have to put our views subordinate to their needs,’ she says. ‘For me, I don’t object to dispensing the contraceptive pill, so why would I object to EHC?

‘We see a range of people coming in for EHC, including those who have had sex for the first time, or those with children who are worried about having another child.

‘This opens up the conversation so, for example, if they’ve had unprotected sex, they might also need a chlamydia test, which we can offer them to take home and post back. We can provide condoms or advice about what kinds of contraception might suit them best – all of which have potential healthcare benefits for them and the wider community.

‘As with so much of what community pharmacy does, we are easier to access than an appointment with a GP, plus we save the NHS money and the patient time, especially as pharmacies open longer hours – which in the case of EHC is even more pressing.

‘To me, the important thing is patient choice. Just because something might not be what you would choose for yourself doesn’t mean it’s not the best thing for your patients.’

Saša Jankovic is a freelance journalist

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