Service Level Agreement and Specification for Local enhanced Service:
Supply of Emergency Hormonal Contraception (EHC) under
Patient Group Direction (PGD)
Service: Community Pharmacy Local Enhanced Service – Supply of Emergency Hormonal Contraception (EHC) under Patient Group Direction (PGD)
Public Health Policy Lead: Sally Handley – Senior Public Health Manager
Public Health Contract Manager: Tanya Makins
Provider: Community Pharmacy Contractors
Period: 1st April 2015 – 31st March 2016
1. Purpose1.1 Aims
The aim of the service is to deliver an emergency hormonal contraception (EHC) service under patient group direction (PGD) and provide sexual health advice through Community Pharmacies.
1.2 Evidence Base - Unintended and unplanned pregnancy (references available on request)
NICE state that the average age of first intercourse in the UK has stabilised for both males and females at 16 years of age. Despite the widespread use of contraception, unintended pregnancy is common. In England in 2011 there were 29,166 under 18 conceptions at a rate of 30.7 per 1,000 females aged 15 – 17 years. Data suggests that true contraceptive method failure accounts for fewer than 10% of unintended pregnancies, the rest arising either because no method was used at the time (30 – 50%) or because the method was used inconsistently or incorrectly
Emergency contraception has the potential to reduce unintended pregnancy rates, thereby reducing the number of abortions is the equitable provision of and easier access to emergency hormonal contraception via pharmacies that has the potential to improve the effectiveness of this contraceptive method by reducing the time interval between unprotected intercourse and initiation of treatment.
1.3 General Overview
This service will require the trained pharmacist to provide an emergency hormonal contraception (EHC) service under patient group direction (PGD) and provide sexual health advice.
The chemist contractor will be reimbursed the cost of the hormonal post coital contraception Levonelle® 1500 plus VAT on cost and a professional fee.
The payment will only be made if the full postcode of the client is provided to the commissioners. In view of this the pharmacist must obtain informed consent from the client to ensure they understand that the information they have shared with the pharmacist will be shared with commissioners for the purposes of evaluation and contracting.
1.4 Objectives
· To improve access to emergency contraception and sexual health advice among menstruating females of all ages 12 years and above especially amongst the teenage population.
· To help contribute to a reduction in the number of unplanned pregnancies and abortion rates especially amongst the teenage population.
· To help contribute to a reduction in the rates of sexually transmitted infections.
· To complement and strengthen the local network of current contraceptive and sexual health services being provided by GPs and Contraception and Sexual Health Services (CaSH).
1.5 Expected Outcomes
The pharmacist will provide an accessible emergency hormonal contraception service wholly acceptable to clients.
2. Scope2.1 Service Description
2.1.1 Definition: Supply of Emergency Hormonal Contraception (EHC) under Patient Group Direction (PGD). This service will require the pharmacist to undertake the appropriate one to one consultation and supply the hormonal post coital contraception Levonelle® 1500 free of charge to menstruating females 12 years and above requesting the emergency hormonal contraception and who are clinically eligible under the patient group direction.
Definition – The trained pharmacist hereafter referred to as the pharmacist.
2.1.2 Where the patient is found not to be clinically eligible under the patient group direction after the appropriate one to one consultation, the pharmacist must provide appropriate advice to the patient and refer/signpost the patient to their medical practitioner, CaSH or out of hours service provider.
2.1.3 Pharmacies will offer a user-friendly, non-judgmental, patient-centred and confidential service.
2.1.4 The pharmacist will provide appropriate support and advice to the patient on emergency hormonal contraception, regular contraception, sexually transmitted infections and consult/refer/signpost to their medical practitioner or CaSH where appropriate.
2.2 Role of the Chemist Contractor
2.2.1 To ensure that as many pharmacists as possible (including locum pharmacists) employed to work in the pharmacy are trained to provide the service and ensure that only those trained pharmacists provide the service.
2.2.2 To ensure that the trained pharmacists are enhanced CRB/DBS checked.
2.2.3 To ensure that provisions have been made in the pharmacy for the one to one consultation to take place in a suitable, confidential and private consultation area (See section 2.6 for required standards of the consultation area).
2.2.4 To ensure the availability of up to date written information and leaflets (see below) in the pharmacy so that pharmacists who are providing the service have adequate access to the relevant information:
· Service Level Agreement and Specification (SLA)
· Current signed Patient Group Direction (PGD)
· Consultation forms and other paperwork relating to the service (Fraser Guidelines Assessment Tool and Safeguarding Checklist)
· Disclosure and Barring Service (DBS) information available at: https://www.gov.uk/disclosure-barring-service-check/overview
· DH (2013) A Framework for Sexual Health Improvement in England. Available at: www.gov.uk
· FSRH (2014) Quality Standards for Contraceptive Services. Available at:
http://www.fsrh.org/pdfs/FSRHQualityStandardContraceptiveServices.pdf
· FSRH (2013) Service Standards for Sexual and Reproductive Healthcare
· FSRH (2012) Service Standards on Confidentiality
· DfE (2013) Working together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. HM Government. Available at: www.gov.uk
· NICE (2014) Contraceptive services with a focus on young people up to the age of 25 years. Public Health Guidance 51. Available at: www.nice.org.uk
· RCPCH (2014) Safeguarding Children and Young People: roles and competencies for health care staff (2014) Intercollegiate document. Royal College of Paediatricians and Child Health
· Contact details of local Contraception and Sexual Health Services (CaSH)
· Family Planning Association leaflet entitled ‘Emergency Hormonal Contraception’ available at www.fpa.org.uk
· PPhC Standards and guidance on confidentiality (2012)
· GPhC Guidance on the provision of pharmacy services affected by religious and moral beliefs (2010)
Safeguarding
· DfE (2013) Working together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. HM Government. Available at: www.gov.uk
· Local safeguarding children procedures. Available at www.nottscc.gov.uk/nscb particularly the chapter on risk of harm relating to sexual activity of young people and information about MASH - Nottinghamshire Multi-Agency Safeguarding Hub- A guide for professionals
· NICE (2014) Contraceptive services with a focus on young people up to the age of 25 years. Public Health Guidance 51. Available at: www.nice.org.uk
· RCPCH (2014) Safeguarding Children and Young People: roles and competencies for health care staff (2014). Intercollegiate document. Royal College of Paediatricians and Child Health
2.2.5 To ensure that there are provisions and processes in place to signpost the patient to another service provider when the pharmacist on duty is not trained to provide the service. This may include signposting patients to another nearest pharmacy with an EHC trained pharmacist on duty. This may involve contacting other pharmacies by phone at the time on behalf of the client to check availability of an EHC trained pharmacist.
2.2.6 To ensure that the relevant poster - ‘Need the emergency pill urgently?’ - is displayed prominently in the pharmacy.
2.2.7 To ensure that pharmacists providing this service signpost patients for chlamydia screening to their GP or CaSH.
2.3 Role of the Pharmacist /Locum Pharmacist
2.3.1 The pharmacist must have completed the required training and have suitable professional indemnity insurance.
2.3.2 The pharmacist must be familiar with the contents of the Patient Group Direction (PGD), SLA, consultation template records, assessment tools, national and local guidance and know where information is located in the pharmacy to signpost / refer patients to local CaSH services where appropriate
2.3.3 The pharmacist must be familiar with national and local guidance on safeguarding children, particularly around risks of young people to sexual abuse and exploitation and know where information is located in the pharmacy relating to this including names and contacts of Safeguarding Children Specialist Advisory Services/safeguarding children health professionals/leads and the Local Authority Children’s Social Care referral points.
2.3.4 The pharmacist must be aware of the legislation governing sexual offences.
2.3.5 The pharmacist will undertake a one to one consultation with the patient in a suitable, confidential and private area. The consultation must include all the issues as requested in the PGD.
2.3.6 The pharmacist will assess the need and suitability for a patient to receive EHC in line with the PGD and give appropriate advice regarding emergency contraception, regular contraception and the avoidance of pregnancy and sexually transmitted infections through safer sex and condom use and the diagnosis and management of sexually transmitted infections.
2.3.7 The pharmacist will ensure that a supply of EHC is made only if the patient is clinically eligible under the PGD.
2.3.8 Where the patient is found not to be clinically eligible under the PGD after the appropriate one to one consultation, the pharmacist must provide appropriate advice to the patient and refer/signpost the patient to their medical practitioner, CaSH services or out of hours service provider. The signposting information must be accurate and relevant to the time when the patient presents at the pharmacy (e.g. it is no use advising the patient to go to CaSH service or their GP during the weekends/out of hour’s period when those services are unavailable). The pharmacist should give advice to the patient on how to access the relevant out of hour’s providers, CNCS, NEMS or Bassetlaw Primary Care Centre based at Bassetlaw Hospital
2.3.9 The pharmacist will provide patients with verbal and written information and leaflets relevant to the service and in line with the PGD including the following -
· That their next period may be early or late
· That a barrier method of contraception needs to be used until; the next period
· To seek medical attention promptly if they experience any lower abdominal pain because this could signify an ectopic pregnancy
· To seek medical advice in 3-4 weeks if the subsequent menstrual bleed is abnormally light, heavy or brief, or is absent, or if they have any other concerns. If there is any doubt as to whether menstruation has occurred, a pregnancy test should be performed at least 3 weeks after unprotected intercourse
2.3.10 The pharmacist will ensure that the consultation is fully recorded on the EHC consultation form and maintain appropriate records as required by legislation and as required as part of the service. The full postcode of the patient is required in order for Nottinghamshire County Council to process claims
2.3.11 In all consultations the patient must sign to say they understand the advice they have been given by the pharmacist and that information will be shared with the commissioner for contracting purposes. A copy of the EHC consultation form must be retained in the pharmacy for 2 years.
2.3.12 The pharmacist must explain to the patient that a copy of the EHC consultation form will be submitted to the commissioners for evaluation and contracting purposes
2.3.13 Where the patient is under 16, the pharmacist will make clear to the patient at the outset that assessments will need to be carried out (i.e. certain questions will need to be asked) during the course of the consultation and that absolute confidentiality cannot be guaranteed. There will be some circumstances where the needs of the young person can only be safeguarded by sharing information with others.
2.3.14 Where the patient is under 16, the pharmacist will assess the patient on Fraser ruling using the commissioner developed assessment form and ensure the assessment is recorded and kept in the pharmacy. The EHC consultation should only proceed where the patient has been assessed as competent to consent to treatment under the Fraser Ruling. Where the patient has been assessed as not being competent to consent to treatment, the pharmacist still has a duty of care to assess the likelihood of harm using the trigger questions contained in the EHC consultation form.
2.3.15 Where the patient is under 16, the pharmacist will assess the likelihood of harm/child protection concerns. If there are any concerns of harm/child protection concners at this stage, the pharmacist should then conduct the risk assessment tool to assess whether the young person or child may be at risk of harm and ensure the assessment is recorded and kept in the pharmacy.
2.3.16 Where the risk assessment has identified a definite need to refer the patient to the Police or Children’s Social Care, the pharmacist should make this referral without delay, as outlined in the Nottinghamshire Safeguarding Children Board procedures, ensuring that the referral is confirmed in writing. The pharmacist may consult with the local Safeguarding Children Specialist Advisory Services or named doctor or Nurse for safeguarding children if additional support and guidance is required.
2.3.17 Where there is uncertainty around the level of risk, or the pharmacist is concerned for the welfare of the young person, then advice should be sought from Nottinghamshire Multi-Agency Safeguarding Hub (MASH) or named professionals as above to ensure joint decisions are made on any further appropriate actions to support the young person. The pharmacist must record all conversations on the Fraser Guidelines Assessment Tool and Safeguarding Checklist. Where the discussions have resulted in a joint decision to refer the patient to the Police or Children’s Social Care, the pharmacist will make the appropriate referral by contacting the police or Social Care, making records of the referral and confirming in writing.
2.3.18 The Sexual Offences Act 2003 deems that sexual intercourse with a child under 13 is classified as rape. Therefore, where the patient is under 13, the expectation is that a referral will be made to the Police or Children’s Social Care. Decisions not to refer must be discussed with the Safeguarding Children Specialist Advisory Services/Named Nurse for safeguarding children or the senior manager of the pharmacy (pharmacy head office/ area manager). Decisions not to refer and the reasons for not referring must be recorded.
2.3.19 Written information should be provided to the patient on sexual and domestic abuse service available should there be any indication that the patient may be at risk and information should be made visible in the pharmacy. Free copies can be obtained from www.Equation.org.uk 0115 9623237 .