Community Pharmacy Emergency Hormonal Contraception Service
Contents
Executive Summary
Aims and intended service outcomes of the service
Brief service description
Resource implications
Purpose of the Agreement
Selection of provider
The Services
Client presents in pharmacy
EHC consultation
Advice to be provided
Information to be provided
Referral
Excluded clients
Accessibility
Payment
Formulary
Staff
Core Competencies
Accreditation
Underpinning Knowledge
PCT Commissioned Workshop
Premises
Resources to support delivery of the service
Quality Indicators
Service Evaluation
Executive Summary
The NHS supply of EHC through Community pharmacists has a crucial role in preventing unwanted pregnancies by providing fast, convenient, local access to EHC without an appointment, often out of hours, maximising the effectiveness of EHC by as much as 10%[1]. Additionally, supply of EHC on the NHS from community pharmacists has been well received by service users[2].
Reducing teenage pregnancy is a priority, including females between 13 years and 25 years of age in the service should contribute to the reduction in teenage pregnancy rates and as such should be seen as an ‘invest to save’ measure[3].
Aims and intended service outcomes of the service
The Emergency Hormonal Contraception Service (EHC Service) aims to:
- Increase access to Emergency Hormonal Contraception (EHC) and sexual health advice
- Increase choice of health care professionals who can provide EHC free of charge
- Reduce the rate of unintended pregnancies, in particular among women under 25 years of age
- Directing clients who fall outside the protocol or who need advice on ongoing contraception into mainstream contraceptive services and appropriate healthcare services.
Brief service description
Females between 13 and 25 years of age who present within 72 hours of unprotected sexual intercourse will be provided with emergency hormonal contraception (subject to clinical circumstances) free of charge.
Additionally, females who present within 72 hours of unprotected sexual intercourse who are in receipt of an income based prescription exemption (income support, income based jobseekers allowance or working families tax credit) will be offered emergency hormonal contraception (subject to clinical circumstances) free of charge.
Clients will also be given advice on the avoidance of pregnancy and sexually transmitted infections (STIs) through safer sex and condom use, advice on the use of regular contraceptive methods and provide onward signposting to services that provide long-term contraceptive methods and diagnosis and management of STIs.
Resource implications
Pharmacies will be paid £15 per consultation to cover pharmacist and staff time, training and other duties as outlined in the services. EHC is reimbursed at cost price (based on drug tariff, Chemist and Druggist or wholesalers list price) plus VAT.
Service Specification
This service specification is underpinned by the Agreement for the provision of Community Pharmacy Enhanced Services (LES Agreement). The LES agreement specifies the terms of service, including duration of agreement, performance management, and should be read in conjunction with this Service Specification.
Purpose of the Agreement
This agreement relates to the Emergency Hormonal Contraception (EHC) Service by participating community pharmacies within Calderdale PCT.
The agreement is for the pharmacy to supply Levonorgestrel Emergency Hormonal Contraception (EHC) to appropriate clients, in line with the requirements of the patient group direction, by accredited pharmacists from accredited community pharmacies within NHS Calderdale.
Selection of provider
The Pharmacies for this service have been selected on the basis of:
- Availability of a suitable consultation area (as defined for the Medicines Use Review service)
The Services
Any client registered with a Calderdale GP practice is eligible to receive advice and treatment under this service. Clients who present to the pharmacy but are not registered with a Calderdale GP must be signposted as outlined as stated below under Excluded clients p6.
Client presents in pharmacy
- Pharmacies will ensure they offer a user-friendly, non-judgmental, client-centred confidential service.
- Pharmacies will ensure that staff refer clients requesting EHC to the accredited pharmacist discreetly and as soon as practicable. See Accessibility section p3 for action to be taken if accredited pharmacist not available.
- Clients who present for over-the-counter (OTC) EHC will not be diverted to this service unless the client states that the cost of OTC EHC is prohibitive and will prevent them from accessing OTC EHC.
EHC consultation
- The complete EHC consultation must be carried out within the pharmacy consultation room (see premises p11).
- The EHC consultation must be carried out by a pharmacist who is accredited with NHS Calderdale to provide the EHC service (see accreditation p9)
- The pharmacist will assess the need and suitability for a client to receive EHC, in line with the PGD and service specification.
- The consultation must be documented on the Patient Record Form.
- Inclusion and exclusion criteria detailed in the PGD and service specification will be applied during the provision of the service.
- Where appropriate supply of EHC will be made free of charge to the client.
- Supply should be recorded on the patients PMR. If the client does not have a PMR entry one must be created on which to record EHC supply.
- The pharmacist will normally supervise the administration of the EHC, unless a valid reason is given not to administer the EHC at that time, in which case the EHC will be dispensed and the client informed to take EHC as soon as it is possible.
- If the pharmacy provides the Chlamydia screening service all clients under 25 should be offered a Chlamydia screen.
The PCT supports the RPSGB guidance that states that If a pharmacist thinks that EHC is not required but the female perceives risk, and despite the pharmacists advice still wishes to take EHC the pharmacist can consider making a supply. Supply in this instance is covered by the PCT PGD and will be paid under this agreement.
Although the RPSGB has issued guidance regarding advance supply of EHC this is not covered by the PDG therefore pharmacists are unable to make an advanced supply using this service. If a request is made for advance supply a pharmacist can offer OTC purchase if they feel it is appropriate.
Advice to be provided
The pharmacist will provide support and information to clients accessing the service including:
- the avoidance of pregnancy and sexually transmitted infections through safer sex and condom use
- how to use condoms
- the use of regular contraceptive methods
- where and how to access services that provide long-term contraceptive methods
- where and how to access STI services
- where and how to access further advice and care.
NB this advice is to be provided whether or not EHC is provided
Information to be provided
Clients under 25 years old should receive the purple Choices pack.
Clients over 25 years old should receive an appropriate selection of information leaflets covering sexual health and on-going contraception.
NB This information is to be provided whether or not EHC is provided.
Referral
- Record referrals on the Referral Form
- Clients who have exceeded the time limit for EHC must be informed about the possibility of use of an IUD and should be referred to a local service, such as CaSH or GP, as soon as possible.
- Refer any client who is identified as unsuitable for the supply of Emergency Hormonal Contraception under the PGD or service specification to a GP or CaSH.
- If a referral is made the pharmacist should make every effort to contact the GP/ CaSH clinic, book an appointment for the client and inform the client of the time and location of the appointment.
- Pharmacists should link into existing networks for community contraceptive services so that clients who need to see a doctor or appropriate healthcare professional can be rapidly referred.
Excluded clients
Clients excluded from the PGD criteria or service specification criteria will be referred by the pharmacy to another local service that will be able to assist them, as soon as possible, e.g. GP, community contraception service, or will be invited to purchase the Pharmacy medicine product if the exclusion from supply via the PGD is only due to an administrative matter, e.g. client not registered with a Calderdale GP, over 25 and but not in receipt of an income-based prescription exemption (income support, income-based job seekers allowance or named on a valid working families Tax Credit NHS exemption certificate).
If the client is excluded from accessing EHC due to a service specification exclusion (i.e. accredited pharmacist not available, client not registered with Calderdale GP, over 25 and not in receipt of an income-based prescription exemption) the pharmacist cannot claim a consultation fee as this exclusion should be ascertained before the consultation.
If following a consultation, a client is excluded or otherwise unable to access EHC the pharmacist can claim the usual fee for the consultation as long as the advice, information and referral has been provided to the client as outlined in the PGD and service specification.
Accessibility
The expectation is that the service is available throughout the pharmacies opening hours (both core and supplementary). The service is to be delivered by the pharmacy for at least 45 weeks of the year with no continuous break of more than two weeks.
When the pharmacy is unable to provide the service the pharmacy has a duty to signpost any potential clients to another provider of EHC, convenient to the client, who are able to provide the service to the client. This may be another pharmacy, CaSH or GP. The client must be informed of all possible providers.
The pharmacy must ensure that the service to which the client chooses to be referred to is able to provide the service in terms of opening times, availability of suitable staff etc. In the case of referral to another pharmacy this would include phoning the pharmacy to check that an accredited pharmacist will be available to provide the EHC service for the client.
These checks must be made before the client leaves the pharmacy.
The pharmacy should also consider whether it is appropriate to provide clients being referred or signposted with information leaflets regarding emergency contraception, ongoing contraception and sexual health.
The pharmacies procedure for dealing with a client who presents for EHC when an accredited pharmacist is not available must be detailed within a SOP, accessible to all pharmacy staff to ensure that any client who presents to the pharmacy is dealt with in an appropriate and timely manner in line with this service specification.
Payment
Remuneration will be made to the pharmacy according to the following:
Service delivery costs will be paid at £15 per consultation to include:
- Pharmacist time to provide the consultation
- Associated staff time to support the pharmacist in providing the service
- Training costs
- Printing and providing information sheets
- Completing claim forms and audit.
Treatments are reimbursed at cost price (based on drug tariff, Chemist and Druggist or wholesalers list price) plus VAT at the appropriate rate (currently 5%) as stated in the Formulary p7.
Payment will be made retrospectively on a monthly basis on receipt of an EHC client summary form for each client and monthly formic submission form at the PCT. NB All claims must be submitted to MONTHLY SUBMISSION, Medicines Management, 4th Floor, F Mill, Dean Clough, Halifax HX3 5AX
Formulary
The pharmacy will hold adequate stocks (taking into consideration the possibility of an unexpected increase in demand) of EHC to ensure that clients can immediately access the necessary treatment.
Levonelle tabs 1500mcg Bayer Schering (1) = £5.37
Prices correct at December 2009. The PCT will notify contractors of change in prices by letter.
Staff
Pharmacies operating the service must be authorised by the PCT to provide the service. This is via a schedule of services authorisation signed by both the EHC service commissioner and the community pharmacy.
Each individual pharmacist providing the service must:
- be registered with the PCT to provide the EHC service
- have signed the current version of the NHS Calderdale EHC PGD retained in the pharmacy
- have a satisfactory CRB advanced check carried out by the PCT
- completed (and maintained) the required training
- be in possession of a current, expiry dated EHC service certificate provided by the accrediting PCT (this may be other than Calderdale PCT)
The pharmacist named in the Locally Enhanced Service (LES) agreement must ensure that all pharmacy staff, including part-time staff and locum pharmacists, receive appropriate training and are aware of the service, how it operates including relevant signposting information and referral procedures, to ensure the pharmacy offers an effective, sensitive and non-judgemental service.
Core Competencies
All pharmacists providing the EHC Service have a professional responsibility to develop, reinforce and update their knowledge and skills in the following areas:
a) Able to communicate with clients appropriately and sensitively [G1, G2].
b) Able to counsel and advise on emergency contraception and regular methods of contraception [G2, G7].
c) Understands how and when to refer clients and when to ask for support and advice [G7].
d) Understands confidentiality issues and is aware of their role in the process of child protection [G8].
e) Understands the different types and methods of hormonal contraception and non-hormonal contraception; their use, advantages, failure rates and complications [G1,].
f) Understands the pharmacotherapy for the full range of available medication and appropriate clinical guidance (e.g. NICE). [G1]
g) Understands and is able to apply the medico-legal aspects of EHC provision in accordance with a Patient Group Direction [G5].
h) Able to demonstrate knowledge of the clinical content of the relevant Patient Group Direction(s). [G1]
These core competencies have been linked, where appropriate, to the general pharmacist competences of the Royal Pharmaceutical Society of Great Britain which are shown in [ ] and are mapped to the General Level Framework (available at
Accreditation
Pharmacists must be accredited to provide the service. To gain accreditation each pharmacist must have attended the PCT Commissioned Workshop session(s) and successfully completed the:
a) CPPE Emergency Contraception Open Learning Programme and accompanying assessment prior to attending the workshop.
b) CPPE Contraception Open Learning Programme and CPPE Child Protection Open Learning Programme and their accompanying assessments either prior to or within 3 months of the workshop.
c) Role Play assessment to an acceptable standard.
The PCT recognises that pharmacists who became accredited prior to 2010 were not accredited to these standards (as defined by the Harmonisation of Accreditation Group (HAG)); however their accreditation is still valid and they can continue to provide the Calderdale EHC service.
Accreditation is proven by possession of a current, expiry dated certificate provided by the accrediting PCT which, if relevant, bears the HAG standard mark.
Pharmacists are expected to re-validate their accreditation at least every three years. This should be in the form of a self-declaration of competency or other method of assessment as considered appropriate by Calderdale PCT.
Underpinning Knowledge
Three Centre for Pharmacy Postgraduate Education (CPPE) learning packs provide pharmacists with the necessary knowledge to underpin the provision of EHC as an enhanced service:
- CPPE Emergency Contraception Open Learning Programme (3 Hours)
- CPPE Contraception Open Learning Programme (12 Hours)
- CPPE Child Protection Open Learning Programme (1.5 Hours)
Successful completion of the Emergency Contraception Open Learning Programme and the assessment is a pre-requisite to attending the PCT Commissioned Workshop. The Contraception and Child Protection Open Learning Programmes and their assessments should be completed before or within 3 months of attending the Workshop. The CPPE programmes provide pharmacists with a record of assessment which must be retained by the pharmacist and copies sent to the PCT. Alternatively, individuals can also allow access to their online records by switching on the CPPE viewer via the My CPPE page on the CPPE website (
Although not mandatory a CPPE Open Learning Programme is available for those Pharmacists who are not familiar with the concept of Patient Group Directions and wish to learn more.
PCT Commissioned Workshop
a) Aim of workshop
To enable Community Pharmacists to become competent to provide an EHC service that includes the supply of a Prescription Only Medicine in accordance with a Patient Group Direction, and understand the clinical, ethical, cultural and legal aspects of this work. The workshop will address relevant clinical issues linked to such medicine use.
b) Objectives of workshop
The workshop should review and support the underpinning clinical knowledge required to provide an EHC service. Pharmacists should experience problematic situations through role-play, and gain confidence in dealing with them. On completion of the training, pharmacists are able to:
- Understand the aims of an EHC service and its place in Contraception and Sexual Health Services overall.
- Understand confidentiality issues and be aware of safeguarding children and vulnerable adults.
- Understand and apply the medico-legal aspects of aspects of the Patient Group Direction - especially as applied to under-age females (i.e. under 16yrs) [Fraser Ruling].
- Undertake the administration of the Patient Group Direction(s), including all necessary record keeping and associated paperwork **.
- Apply the clinical content of the Patient Group Direction(s).
- Be aware of the details of when to carry out a pregnancy test, and the actions to be taken following the result.
- Understand how and when to refer clients (signpost) and when to ask for support and advice from the local Contraception and Sexual Health Services.
- Counsel and advise clients appropriately and sensitively, and refer for further contraceptive care.
- Know what sources of support are available to the pharmacists involved in the provision of this service.
c) Features of the Workshop