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Women’s health: Offering an emergency hormonal contraception service

contraceptive pill in pharmacies

By Rachel Carter

03 Aug 2020

Sanjay Doegar says his pharmacy has been able to help a lot of women and young people by offering the locally-commissioned emergency contraception service.

Service type: Emergency hormonal contraception.

Name of pharmacy: Ruislip Manor Pharmacy, Hillingdon.

Name of pharmacist: Sanjay Doegar.

Why did you start offering the service?

We’ve been offering the service for somewhere in the region of eight or nine years.

We had a pre-registration pharmacist many years ago and he was very keen on additional services. He suggested that he could do all of the ground work on this service and then we would be able to offer chlamydia testing, give condoms and advice, as well as emergency hormonal contraception (EHC), as part of much wider and more comprehensive scheme. So, it was a push from him in a way that brought us to the decision to offer the service.

The service is locally commissioned and at that time there were a lot of teenage and unwanted pregnancies. When the commissioners looked into it, they realised that sometimes young people don’t have the money, don’t know where to go, or can’t go to some of the other clinics that are dotted around and often attached to hospitals. It can be quite a daunting prospect for young adults to take on that journey as it were, whereas having a local community pharmacy where a person may be passing by anyway, or have some sort of established relationship with, tends to work much, much better.

That’s what we’ve found – when it first launched, we started to see a completely different cohort of people. It was quite a young age of population, who weren’t naturally coming into our pharmacy, and over the years that’s built up. We’ve been able to help a lot of women and young people.

How much did it cost to set up the service?

We had to make sure we had an adequate consultation room, but we already had one that met the requirements – private, confidential and comfortable.

There were some very minimal costs, but it was more about organising yourself, being ready to deal with the clients who might need your help and the time that takes. So, there was a time cost in that sense, but if you already had the room it wasn’t a massive additional reorganisation.

What, if any, training did you or other team members have to undergo?

There are quite a few components that you have to satisfy to a) be competent and b) increase your confidence. We’d always dealt with the occasional person, but with selling pharmacy medicines there’s a clear direction of questioning. With this service, the cohort is younger and sometimes more vulnerable, so you’ve got to come at it slightly differently.

We did some extra CPD learning and attended some courses, including on safeguarding, supporting vulnerable adults and young adults, and grooming. Many different components were addressed to try and highlight some of the potential risks of making a supply, or potential help that patients might need. It was very informative and eye-opening. The area we’re based in is a relatively conventional place, but some of the stories we heard are quite shocking really. It was a big learning curve.

Most of the training was provided by the CPPE. This included online training that you had to complete to meet all of the requirements. They also held some face-to-face events, which shadow the actual online modules and are very good. There would be an expert speaker, a question and answer session, and participants could put forward any particular scenarios that they have come across, which they felt others might be able to learn from.

The commissioners have also offered a few refresher training evenings over the years, to provide guidance on the requirements of the service and share any updates, such as when a new product has been introduced.

In a nutshell, what does the service involve?

In normal times [before Covid-19], we acknowledge that the patient needs some help or support and we show them to the consulting room. We explain that the pharmacist will be with them shortly. We want to put them at ease and let them know that we’re going to try and do our best to help. We don’t say ‘yes we’re going to give you this supply’, because we don’t know that for a fact without first going through all the questions with them.

Before starting the consultation, the pharmacist will ask the patient if they are happy as they are or if they need anyone else with them. This is to make sure that they feel confident and comfortable in doing this consultation – sometimes it’s quite a big step for them and it can be hard to come forward.

If they’re happy to proceed, then we’ve got quite a comprehensive PGD and we go through that form with them. This includes asking when it [the sexual activity] happened, whether they are taking any medications, and if there is anything else we need to know about. We also answer any questions they may have. At the end of that process, in the vast majority of cases, it would lead to us to being able to supply the EHC.

Depending on how long ago the sexual activity happened, we have two possible treatments, EllaOne and Levonelle. We can also signpost patients onwards if it has gone beyond the timeframe for those treatments. If everything is straightforward, then we will offer the patient some water to take the medication there and then, if they want to do that. It’s not so tight now, but the requirement in the past was that we should supervise the taking of the medication. We also advise that if they are sick within a few hours then they should return to the pharmacy, in case they haven’t absorbed the pill.

The beauty of this service up until very recently is that it was very comprehensive. We would tell patients that if they’ve had unprotected intercourse with anyone then it’s also highly recommended to do a chlamydia test. We were able to give them the test physically in their hand and they could go away and do it. We still recommend it, but now that’s been changed over to an online portal where they have to log-in and request a test to be sent to their home. We’ve found this isn’t ideal for younger people – older people have no problem at all – but younger people are much more anxious to keep it a little bit under the radar from their family.

We haven’t done the service for a little while now because of Covid-19, but some of the questions we would also ask include are you happy and do you have an adult that you are happy to talk to. We’d get all that kind of feedback from them just to make sure that the sex was consensual, and that there was nothing underhand or suspicious about their activity.

The final bit of the jigsaw is we give the patient a supply of condoms. In this area, we have the C-Card scheme. This is a condom card scheme that basically gives young adults free access to condoms. Often they can’t afford them, or they are embarrassed, or there are other factors as to why they can’t access them. We give them some condoms so at least, if they carry on with their sexual activity, they are not going to be putting themselves at further risk. We talk about sexually transmitted infections as well.

It’s a very comprehensive scheme and available to any young person up to their 25th birthday. There is only a limited budget available and the thinking is that if you’re in your mid-20s, hopefully you would be able to afford to purchase something, if you found yourself in that situation and needed to.

Are there any opportunities to sell over the counter or prescription products during the consultation or after it?

No. EllaOne or Levonelle, and condoms, are supplied for free.

We talk to patients about pregnancy, the risks, and the rate of failure [of the EHC] and that if the woman doesn’t experience a period as expected, then she might need to do a pregnancy test. But that wouldn’t lead to a direct sale, it’s more about giving advice that they need to be mindful and if they don’t have a period when they normally expect to then they will need to act.

How have patients responded to the service?

Most people are very grateful just to get that time and space with you, and to be able to ask any questions. It was mostly young people at the beginning and what we’ve found over the years is that they would come in, and then they were coming back with their friends. So, we had been the support for someone who was going through a tough time and then they’d told a friend that they could get the same help in this pharmacy, so that’s been quite nice.

We also do a questionnaire and the general level of satisfaction is extremely high. Patients are really happy that this service is available, that they can access it quite easily and quickly, and obviously for some people the fact that it is free is a big bonus. I think the feedback from the patients and those surveys has been very, very good.

Roughly how often each month do you carry out the service?

Anywhere between eight and 15 times each month.

How much do you charge for the service?

It’s free to the patient within the specified parameters (up to 25th birthday).

Roughly how much a month do you make from offering the service?

It varies, but around a few hundred pounds each month.

Would you recommend offering this service to other contractors?

Yes, but not just for the sake of it. I think all pharmacists are doing a lot now and we’re being pulled in so many different directions. So, just saying you’re doing another service and not being able to perform it well is probably not going to be so good, and is probably going to add stress unnecessarily. But if it’s well paid, you can organise yourself well, and you’ve got buy-in from the staff, then like all things it’s quite satisfying to be able to help people.

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