Are community pharmacists trying to protect their EHC secret treasure?

Community pharmacist James Milner

Since the Royal College of Obstetricians and Gynaecologists published the ‘Better for Women’ report, there has been much talk circulating around the idea of making emergency hormonal contraception (EHC) available as a general sale list (GSL) product for women to purchase off the shelf without having a consultation.

This has got me thinking…

Is this something that we should be pushing for?

What are the reasons we don’t currently allow the public to self select the morning after pill?

Why isn’t it available to pick up from your petrol station while you fill up or down aisle 4 of your local supermarket with today’s newspaper and a meal deal?

Is it because the medication is unsafe or dangerous?

Not really, levonorgestrel has been widely used for a number of years and has a good safety profile. So why does the pharmacy profession insist upon a mandatory consultation for every single woman who requests EHC?

The fact of the matter is, emergency contraception is not as simple as it first seems, it’s not a one size fits all approach, and that is where we as a health care professionals can have a massive positive impact for women who need EHC.

I’m always surprised at how most of the public seem to be completely unaware of how ineffective EHC is during large parts of their cycles, how their weight/BMI or concurrent medication may alter the dose they need to take and the fact that there is a choice between different types of EHC. Not all of these will be suitable for every woman and not all of them will be equally effective.

Now, imagine these tablets are available from your local corner shop in between the paracetamol and ibuprofen. How are the general public meant to make the decision about which pill is most effective for them at that specific moment in time, with no guidance available apart from the marketing materials provided by the manufacturers? It’s hard enough for us to understand and keep up to date with the current FRSH guidelines and we’ve had years of degree level training to help us do this.

I would argue that removing our input would in fact be doing women a disservice.

This is all without even going into the safeguarding issues, the ability to refer to the more effective IUD fitting services, counselling on and testing for STIs, and providing advice on future contraceptives.

So with all this value that we can add to a simple request for a morning-after pill, why are RCOG making the recommendation for the MHRA to reclassify it as a GSL product?

The RCOG report states that the consultation that I argue adds so much value also “adds a further barrier to access since many girls and women report that this consultation leaves them feeling uncomfortable, embarrassed or judged”.

This statement is backed up by a study of 30 pharmacies conducted in 2018 by BPAS. They said that although on the whole pharmacists provided a non-judgemental service once they were dealing directly with the client, in more than half the cases women had to ask at least two people before help was provided, some pharmacists insisted on women providing proof of age and a negative pregnancy test before supplying EHC, some women were sent away and 10%  of women received a poor or unprofessional service.

This has led BPAS to take the view that any advantage given by the consultation is offset by the obstacle it poses.

To be honest, if this survey is indicative of the experiences of women across the country I am not surprised by the knee jerk reaction to ask for EHC to be available via GSL. This will cut out pharmacists altogether.

But I still don’t think this is the right way.

We need to work at breaking down these barriers whilst still retaining the excellent benefits we can provide. This report should serve as a wake-up call to the profession. A Royal College and a leading charity are advising that pharmacists should just be bypassed entirely, this is not a good sign.

How do we remove these barriers but keep the benefits to our patients?

Here are some of my suggestions:

• Make all EHC free in every single pharmacy across the country. And if this can’t happen right away, then we need to reduce our prices, there’s no good reason we should be charging £20-£35 for a single dose of EHC, this just screams greed to the public and is not a good look for pharmacy.
• Let’s get rid of these locally commissioned services where you have to attend a separate face to face training event across every county you want to practice in. These training requirements present a barrier of access to pharmacists wanting to provide these services.  Let’s replace them with a single high-quality national service, Wales and Scotland have a national service why can’t we?
• Provide a framework that encourages contractors to sign up to the service and guarantee service provisions during all opening hours. This has been done with CPCS with 8,649 out of 11,600 pharmacies signing up just one week after the service went live.
• Heavily advertise the service in pharmacies, normalise the subject, it shouldn’t be a taboo subject any more, we are talking about providing a medical service here. And for those who don’t feel comfortable talking about it, make it very clear with prominent signage that anyone can request a private consultation with a pharmacist at any time without having to explain the reasons why.
• Provide an integrated service: the National chlamydia screening programme, free condom distribution, and advising on future contraception choices, including the promotion of LARCs should all be covered during these consultations.
• Revisit the ability of pharmacists to refuse to supply EHC based on religious or moral beliefs. EHC is widely accepted to work by delaying ovulation by a few days, so conception can not occur, if conception has already occurred, it does nothing. How can we as a profession accept patient care being compromised by a delay in treatment if we know that EHC does not cause a termination?
• Somehow allow our consultations to be audited to allow us to reflect upon our consultation skills to ensure we can never be perceived as being unprofessional or judgemental during a very sensitive consultation.

Hopefully, offer a supply of ongoing contraceptives during the consultation if the MHRA decide to switch POPs from POM to P (another one of RCOGs recommendations).

This blog focusses on just one of many recommendations from the Better for Women report: that EHC should be reclassified as a GSL.

While I don’t agree with their recommendation, I do understand how they reached their conclusion.

This objection to it going GSL is not because I’m a pharmacist wanting to guard my secret treasure that only I possess – it is because I want women to be able to access high quality, effective contraceptive advice and products on demand, and I truly believe pharmacy is the best place to provide that careful balance of accessibility, safety and efficacy.

James Milner is a community pharmacist from Dudley. You can find him on Twitter by clicking here.