Contraception in community pharmacy – a toolkit for servicedelivery and development

(Draft 1 2010)

Contents

Introduction

Suggested timeline

  1. Engaging stakeholders
  1. Securing funding
  1. Developing the patient pathway
  1. Writing a service specification
  1. Developing a patient group direction
  1. Identifying pharmacies
  1. The training course
  1. Preparing documentation
  1. Communication and advertising the service
  1. Data collection and evaluation

Appendices

Introduction

Background

In 2009 Southwark and Lambeth Primary Care Trusts began a year-long pilot project to provide oral contraception in community pharmacies. The aim of the pilot is to increase access to contraception for sexually active young women who are not currently using contraception, particularly those who regularly use emergency hormonal contraception. Southwark and Lambeth have some of the highest teenage pregnancy rates in the UK and it is hoped that increased access to contraception will help address this.

The service started in October 2009 with three pharmacies providing oral contraception to local women aged 16 and over. The service also provides information and referral for long acting reversible contraception (LARC).

Southwark and Lambeth PCTs initiated the early stages of the development of this project in 2007 with the Modernisation Initiative, a 3 year transformation project funded by Guy’s and St. Thomas’ Charity. The oral contraceptive pilot has continued to develop with support from NHS London through funding from the Department of Health.

Aim of the toolkit

This toolkit has been developed by Southwark and Lambeth PCTs to provide information to other PCTs in order to assist them with setting up an oral contraceptive service in community pharmacy, utilising a university module as training for pharmacists. It contains notes on setting up the service and appendices of relevant documents developed by Southwark and Lambeth PCTs.

Southwark and Lambeth PCTs are happy for these documents to be usedand would request acknowledgement where this happens.

Contact information

For more information about the oral contraceptive pilot project in Southwark and Lambeth, please contact:

Judith Parsons

Programme Manager

Southwark Primary Care Trust

Primary Care (1st Floor)

PO Box 64529

London SE1P 5LX

020 7525 0336

1

The oral contraception pilot programme is funded by NHS London

Suggested timeline

ACTIVITY / MONTH
Month 1 / Month 2 / Month 3 / Month 4 / Month 5 / Month 6 / Month 7 / Month 8 / Month 9 / Month 10
Funding secured / 
Participating pharmacies/pharmacists selected / 
Application deadline for university course / 
Honorary contracts with clinics completed and clinical placements provisionally block booked / 
CRB checks for pharmacists completed / 
Occupational health checks for pharmacists completed / 
Patient group direction finalised / 
Service specification developed / 
Patient pathway developed / 
Clinics given pharmacists’ details and pharmacists given details of clinical placements / 
University course / 
Clinical placements / 
Patient record template completed to be used during university course / 
Service paperwork (data collection etc.) completed and compiled for each pharmacist / 
Deadline for clinical assessment portfolio submission to university / 
Course results released to PCT / 
Inform pharmacists of course result / 
Information session for pharmacists on PGD / 
Pharmacists complete baseline survey for later evaluation / 
Produce and disseminate service promotion material / 
Pharmacies commence provision of service / 

1

The oral contraception pilot programme is funded by NHS London

1. Engaging Stakeholders

It is vital to engage key stakeholders from the outset of service development and ensure sustained involvement in all aspects of the planning. Southwark and Lambeth set up a programme steering group which included the following key stakeholders:

•Sexual and Reproductive Health Consultants

•Primary care and sexual health commissioning

•Medicine’s Management

•Local Pharmaceutical Committee

•Community pharmacy

•King’s College London

•Public Health and Health Promotion

•Teenage Pregnancy

2. Securing funding

Service costs for establishing and providing contraception in community pharmacy are relatively low, and in the long run this is likely to be a cost-saving measure. It is hoped that through providing contraceptive consultations in community pharmacy, the following results will be observed:

  • An increase in women using oral contraception
  • A reduction in EHC use
  • Contribution to an increase in LARC uptake and adherence
  • Contribution to a decrease in unintended pregnancies
  • Contribution towards a decrease in terminations of pregnancy

Funding the programme now is likely to mean cost-savings in the future.

Estimated costs per pharmacy for oral contraceptive in community pharmacy programme (please note this accounts for two pharmacists to be trained per pharmacy)

Item / Cost (in £) / Per unit / # of units / Total (£)
University course / 580 / Per pharmacist / 2 / 1,160
Backfill for university / 940 / Per pharmacist / 2 / 1,880
Backfill for SRH competency assessment / 752 / Per pharmacist / 2 / 1,504
Backfill for SRH service staff / 1,000 / Per pharmacist / 2 / 2,000
Pharmacy payment (max. 150 consultations) / 4,000 / Per pharmacy / 1 / 4,000
TOTAL ESTIMATED COST PER PHARMACY / 10,544
Item / Cost (in £)
PGD training evening / 500
Advertising the service / 5,000-10,000
TOTAL EXTRA ESTIMATED COSTS PER BOROUGH / 5,500 - 10,500

3. Developing the patient pathway

Developing a patient pathway is an important step in defining the service. Below is the patient pathway developed by Southwark and Lambeth PCTs.

4. Writing a service specification

It is suggested that the service specification is developed as early as possible. The following people need to be involved in writing the service specification:

  • Programme Manager/PCT lead
  • Sexual health service commissioner
  • Local Pharmaceutical Committee (LPC) representative
  • Steering group

Southwark PCT’s service specification can be found as Appendix 1.

5. Developing a patient group direction

A patient group direction (PGD) could be developed by adapting an existing PGD for a similar service (such as EHC), or developed anew.

The development of a PGD would need to involve:

  • Medicines management pharmacists
  • Sexual and reproductivehealth consultants
  • PCT medical lead

Points for consideration:

  • Define the upper and lower age limits
  • Include patient confidentiality guidance
  • Engage stakeholders to ensure they are happy with the service that will be provided by community pharmacists. This may involve obtaining comments and making amendments to the PGD until all are satisfied with it
  • Define clear exclusion criteria and establish the action pharmacists should take if faced with patients they cannot treat (i.e. clear referral pathways)
  • Detail how pharmacists can access clinical support
  • Define action to take if faced with Adverse Drug Reactions (ADRs)
  • Ensure the training provider has access to the PGD so it can be incorporated early into the pharmacists’ training.

For copies of the PGD please contact Southwark PCT.

6. Identifying pharmacies

Suggested considerations when choosing pharmacies to participate in the service are:

  • Pharmacies in areas of high teenage pregnancy
  • Pharmacies in areas accessed by resident population
  • Pharmacies providing high numbers of EHC
  • Pharmacies with the capacity to provide oral contraception as a drop-in service
  • Pharmacies where both management and pharmacists have demonstrated a commitment to deliver quality sexual health services

One point for consideration is whether to train one, two or all pharmacists in each participating pharmacy. In Lambeth and Southwark two pharmacists have been trained per pharmacy in order that the pharmacy has capacity to provide a consistent service throughout the year. However, it can be more difficult for pharmacies to release two pharmacistssimultaneously for training, and some pharmacies may be able to provide a good service through training a single pharmacist.

The service has been successful where a small group pharmacy (i.e. more than two pharmacies in a group structure) provide the service. Service delivery has been maintained through monitoring, support and training and the current service is delivered as per specification.

7. The training course

Southwark and Lambeth PCTs have worked with the Department of Pharmacy and Florence Nightingale School of Nursing and Midwifery at King’s College Londonto develop an MSc accredited module (15 credits) to provide pharmacists with the training required to provide oral contraception. Clinical placements are completed as part of the training.

Where PCTs use a university module as training for provision of contraception in pharmacy, the following should to have been completed before the start of the course:

  • CRB checks for pharmacists
  • Occupational health checks for pharmacists
  • Honorary contract between clinics where clinical placements are taking place, and the PCT
  • Provisional block booking of clinical placements
  • Letter from PCT to clinic recommending pharmacist and confirming their details
  • Letter to pharmacist outlining placement details so they can arrange locum cover
  • Organisation of extra clinical placements as required

It is important to ensure and facilitate a good flow of communication between the clinics and the university, and to provide support to the pharmacists on the course. It is also useful to evaluate the course from the perspective of pharmacists, course providers and clinical mentors, in order to inform any subsequent courses.

8. Preparing documentation

The following documents need to be developed. We have found it useful to prepare a folder for each pharmacy containing copies of:

  • Contact list (programme management, PGD queries,on-call clinical service contact)
  • PGD
  • Monthly monitoring forms
  • Service specification
  • Patient pathway
  • Chlamydia screening care pathway
  • Patient record forms
  • Referral forms (to sexual health service)
  • Fax sheet to GP
  • Service user questionnaire
  • Local child protection information (including information on and contacts for safeguarding children and vulnerable adults)
  • Contact list of local services providing contraception and sexual health services
  • Information on how to order health promotion leaflets

Southwark and Lambeth PCTs’ patient record form, pharmacy activity form, time and motion data form and ethnicity formcan be found as Appendices2-5.

9. Communication and advertising the service

Southwark and Lambeth PCTs have developed a poster and Z-card advertising the service. We are happy for other organisations to use this design. Please contact Southwark PCT for further details.

Southwark and Lambeth launched the service with a press release two months after the service started. At this point the service was advertised within the participating pharmacies through a poster. The press release can be found as Appendix 6.

Further targeted advertising wasconducted a few months after the service started. This includes the distribution of Z-cards and posters in local youth venues.

Points for consideration:

  • Who is the target group?
  • Where and how will you advertise?
  • Do you want to advertise before the service starts or wait until the service has been running for a while?
  • Consider conducting focus group sessions to gain information about how the target group(s) might react to the service and advertising and to identify the best means of communication (e.g. websites, radio channels, posters, leaflets, types of venue)
  • Ensure other colleagues and stakeholders are kept informed, for example, at pharmacy forums, and through PCT bulletins

We chose a slow start so that the pharmacists could adapt their services within the pharmacy incrementally and get used to delivering the service. Pharmacists began with targeting service users on requesting EHC before advertising the service within the pharmacy and then externally.

10. Data collection and evaluation

Suggested elements of evaluating the service include the following.

Before the service starts:

  • Collect baseline data from pharmacists
  • Collect baseline data from potential service users by conducting focus groups

During the running of the service:

  • Collect monthly activity and monitoring data from pharmacies
  • Collect time and motion data from pharmacies to monitor consultation times
  • Ensure service users complete an evaluation form
  • Consider conducting quarterly evaluations using mystery shoppers, service user interviews and focus groups
  • Collect data from pharmacists every quarter to compare against baseline data
  • Adapt the service as necessary during the pilot phase, perhaps on a quarterly basis

Who needs to be involved:

  • Pharmacists
  • Programme Manager/PCT
  • Public Health
  • Patient and Public Involvement
  • Service users
  • Young people’s health groups
  • Mystery shoppers

Points for consideration:

  • Begin setting up evaluation from the very beginning of the service and gather feedback from all involved (e.g. from pharmacists and from training providers, from patients using the service)
  • Consider the use of electronic methods of data collection or patient-held records
  • Ensure IT/Information Services approve the data collection
  • Consider conducting monthly monitoring visits during the pilot phase
  • Contingency planning in the case of pharmacy staff turnover, pharmacists failing the training course or pharmacies not able to provide the service

The service user questionnaire can be found as Appendix 7.

Appendix 1 – Southwark PCT’s Service Specification

Service Specification for

Sexual Health Community Pharmacy PILOT – Oral Contraceptives

Provision of Combined Oral Hormonal Contraception (COC) to women aged 16 and over. Provision of Progestogen Only Contraceptive Pills (POP) to women aged 16 and over according to the PGD.

1.Service description

1.1For the purpose of this specification ‘Oral Contraceptives’ (hereafter referred to as OC) is defined as Combined Oral Contraceptive Pills or Progestogen Only Contraceptive Pills.

1.2For the purpose of this specification, ‘Combined Oral Contraceptive Pills’ (hereafter referred to as COC) is defined as any of the medications listed as COCs in the Patient Group Direction (PGD) Appendix A.

1.3For the purpose of this specification, ’Progestogen Only Contraceptive Pills’ (hereafter referred to as POP) is defined as Progestogen Only Pills and as any of the medications listed as POPs in the PGD Appendix B.

1.4For the purpose of this specification, provision of Oral Contraceptives (OC) to women aged 16 and over will hereafter be referred to as ‘OC service’.,

1.5The supply of the OC service will be made free of charge to the service user.

1.6The pharmacist will provide general advice and support to those seeking advice on contraception and signposting to specific services where appropriate. However, the pharmacist must be responsive to service users who do not fulfil the criteria for OC service and assist them in finding the correct service, i.e. General Practitioner, Sexual and Reproductive Health clinic, Genitourinary Medicine (GUM) clinic.

1.7In the delivery of this service commissioned by Southwark PCT the pharmacist must show awareness and be responsive to the needs of young women who access the service and follow Young Person Friendly guidelines.

1.8The contract to provide the OC service to the identified service user group is with the Contractor and not the individual pharmacist employees. It is the responsibility of their individual employers, via this specification, to enforce this.

1.9The pharmacist must ensure that their professional indemnity cover provider has confirmed that these activities will be included in their policy.

1.10Any young woman in who fulfils criteria within the Patient Group Direction (PGD) may access free OC. The homeless are not excluded from this service.

2.Aims and intended service outcomes

2.1To provide oral hormonal contraception and the accompanying advice to women 16 and over as specified in the PGD.

2.2To improve access to sexual health services and sexual health advice.

2.3To provide relevant health promotion literature to service users.

2.4To signpost service users to other health and social care services and to act as a gateway to other services (e.g. key working, prescribing, other Sexual Health (SH) services, sexually transmitted infection (STI) screening, primary care services, etc) with information provided by Southwark PCT.

3.Service outline

3.1The contractor must be able to provide the service for at least 5 days a week. One day of this regime must be a Saturday. The service must be provided with no more than two weeks’ break per annum.

3.2Any requesting service user will be seen as soon as possible. If they are unable to be seen immediately, they must be given the opportunity to make an appointment or be signposted to other services.

3.3It is the responsibility of contractor to have a list (that the PCT maintains, updates and distributes) of all current service providers, to give to all potential service users if they are unable to fulfil point 3.2.

3.4The contractor must ensure the pharmacy premises has a designated area in which the service user can be seen privately and have their confidentiality maintained.

3.5Every OC service user contact must be recorded on a service user assessment and record sheet, as per the PGD. These forms are to be treated as confidential and must be stored in a secure area, preferably under lock and key. They should be stored in the pharmacy premises. Access to the records is by the pharmacist only. Authorised Southwark PCT staff may wish to access these records from time to time, for audit purposes. They should be filed in such a manner that allows for easy retrieval.

3.6The pharmacist must ensure that they access support when appropriate. Pharmacists can access pharmacy support from the following sources:

-Monday to Thursday: Ask for the on-call consultant from either the Artesian sexual health centre (tel: 020 3049 7950) or the Walworth clinic (tel: 020 7703 3262)

-Friday to Sunday: Lister health centre (tel: 020 3049 8430) and ask for the senior medical practitioner on-call.

3.7The criteria for supplying OC must be adhered to at all times.

3.8As well as supplying OC, the pharmacist also has a duty to provide the service user with appropriate contraceptive information, STI information and associated health promotion advice/literature. This will include information on other primary and secondary care providers as appropriate, to be provided by the PCT.

3.9The contractor must ensure that all other pharmacy staff that may have contact with potential service users are trained accordingly. This will include areas such as confidentiality, alternative services in the area and how to seek urgent advice.

3.10The contractor must designate window space to advertise these services. This includes information on how else to obtain this service locally.

3.11The contractor must provide Southwark PCT with information on service availability and must advise on any changes to this availability. Southwark PCT will advise NHS Direct of the changes.