Report of Six Month Pilot Pharmacy Chlamydia Awareness Scheme

Report of Six-Month CASPHER Pilot Pharmacy Chlamydia Awareness Scheme October 2004 to March 2005.

Report of Pilot Pharmacy Chlamydia Awareness Scheme

October 2004 to March 2005

Background

Aims and Objectives

Operation of the Pharmacy Scheme

Results

Costs of the Service

Next Steps

Acknowledgements

Appendix 1 – Standard Operating Procedure (version 1) Pharmacy Chlamydia testing.

Background

The Hull & East Riding Chlamydia Awareness Screening Programme (CASPHER) has been operating since April 2003 as part of the DOH National Chlamydia Screening Programme. In order to increase access to screening, in March 2004 the Local Pharmaceutical Committee were asked by CASPHER to investigate the feasibility of using community pharmacy sites to distribute Chlamydia tests for self-use at home to under 25 year old women. In partnership with the Pharmacy Development Group and Pharmacy Research Network a six month pilot project was designed for pharmacies in four Primary Care Trusts in Hull & East Riding to run from October 2004 to March 2005. This is the first Chlamydia screening service, involving community pharmacists offering tests for self-use in England.

Aims and Objectives

The aim of the service was

To increase the access to Chlamydia tests for under 25 year olds and provide targeted sexual health education to young adults in the pharmacy.

The specific objectives were to

Increase the public health role of community pharmacists by providing sexual health information to young adults
Encourage young women who are sexually active to participate in Chlamydia screening
Test the acceptability of self-administration and postal return of screening tests.

Five outcome measures were to be assessed:

The number and distribution of pharmacies participating in the scheme

The number of Chlamydia tests issued by the pharmacies

The number of tests returned to the laboratory by post and proportion of positive results

The number of clients reporting for treatment and contact tracing

Client satisfaction with the pharmacy service

Operation of the Pharmacy Scheme

Two training courses were run for pharmacists in July and August 2004 at which 44 pharmacists attended. The scheme operated from October 2004 to March 2005 in the 25 pharmacies, which offer EHC under patient group directive. Free Chlamydia tests were offered to clients under 25 years old from these sites. Not all pharmacies started the scheme in October due to issues with supplies of resources, the long gap between end of the training and start of the scheme, uncertainty of how to raise the subject with clients, time pressures etc but following a third training meeting in January 2005, and all pharmacy sites were operational by end of January 2005. An interim report was sent to pharmacies in February with a letter (see appendix) In total 52 pharmacists have completed training, which covers locums who work regularly in the 25 branches.

Patient evaluation forms were designed. Initially it was intended that these would be given out by the CASPHER nurses to clients when they came for treatment. After the second training session in January it was agreed by the pharmacists to include the evaluation forms in the envelopes with the test kits to be posted back to CASPHER or given to clients to complete and post back to Conifer House with the Chlamydia tests.

The scheme had minimal advertising. The CASPHER project included the pharmacy scheme in their information for the public. One article in the local newspaper (Hull Daily Mail) explained about the service. Each pharmacy in the scheme was supplied with a poster to display in the pharmacy window. All community pharmacies were informed about the scheme by letter so that if they received enquiries they could refer clients to the pharmacies offering the scheme.

A telephone interview was given with each pharmacy on 14th April 2005 to check views of pharmacists participating with relation to sexual health education role, confidence in raising the issue with clients, future roles for pharmacists, evaluation forms and poster displays.

Results

1. Participation of Pharmacies

In total 25 pharmacies were included in the scheme. Seven in Eastern Hull PCT, five in East Yorkshire PCT, eight in West Hull PCT and five in Yorkshire Wolds and Coast PCT. Since the start of the scheme there are seven new pharmacy sites offering EHC across the four PCT’s but these have not been included in the Chlamydia pilot.

2. Chlamydia Tests Issued

Out of the 25 pharmacies participating Chlamydia tests have been given to clients at thirteen sites over six months

PCT / Accredited Pharmacies / Pharmacies issuing tests / Number of tests issued
Eastern Hull / 7 / 3 / 13
East Yorkshire / 5 / 3 / 15
West Hull / 8 / 4 / 75
Yorkshire Wolds & Coast / 5 / 3 / 7
Total / 25 / 13 / 110

3. Number of tests returned

Thirty six tests were recorded by the laboratory as received from pharmacy sites which is a 33% return rate. Three tests were positive for Chlamydia but negative for gonorrhoea.

4. Number of clients reporting for treatment

All 3 clients with positive tests attended Conifer House for treatment.

5. Patient Satisfaction with the service

This has proved very difficult to measure and the pilot has raised many unanswered questions regarding the acceptability of the scheme. Four evaluation forms have been filled in by clients and received back by CASPHER. All were positive and complementary but without more feedback from the 110 clients who took test kits from the pharmacies we cannot know clients views on the service.

All pharmacies in the scheme were telephoned at the end of the six months to see what their views were on the success of the scheme and to ask their opinion about the feasibility of the service. (See Appendix 1) We were especially interested to reflect on possible reasons why no tests were issued or clients did not accept the tests when offered them or took the tests away but apparently did not use them or return them in the post?

The following reasons were sited (in order of frequency in which they were raised by pharmacists as concerns)

No advertising of the scheme
Women accessing EHC were above 25 years old
Clients too embarrassed or in a hurry to leave at time of EHC consultation so no time to explain Chlamydia test thoroughly
Paperwork and forms too complicated for pharmacy use and for clients to understand
No accredited pharmacist in the pharmacy to offer the service
Pharmacist short of time in EHC consultation
Pharmacist forgot to offer test as it had not become routine to do so as opportunity so rarely occurred and reluctant to raise the issue with teenagers
No referrals from GP surgeries
Clients rarely ask for information or if they do they do not then accept the test offered.
Women say they do not need a test because they are in a stable relationship

There were some suggestions from pharmacists about how the scheme should be improved. These were:

More targeted advertising at younger age group e.g. in schools and colleges
Design simple paperwork with an information leaflet specifically about the pharmacy scheme
Service should be offered to males also
Include sexually transmitted infections as a health promotion campaign under new contract essential services.
Reassess pharmacist’s fee for offering the service

Costs of the Service

Pharmacists were paid a £2.50 fee per test they gave out. The total cost of professional fees for 110 tests was £275. Other costs of the pilot scheme included costs of three training meetings for pharmacists and administration costs. All other costs such as laboratory costs, nurse treatment time, publicity, test kits etc were met by the CASPHER project.

An award from PSNC for £2,500 was paid to the LPC and has been used to meet the costs of the professional fees and administration costs.

We recognise that the £2.50 fee per test does not accurately reflect the time taken to counsel clients about chlamydia infection and how to administer the test as for some clients it can take longer than 5 minutes to do this effectively.

Next Steps

I have asked CASPHER if it is possible to carry out an audit of the 44 tests supplied by one pharmacist to see how many were returned to laboratory. If the return rate is higher than the average we can look closely at the factors that may be contributing to this.

In order to design and commission appropriate and cost effective services more research is now needed into

-beliefs and attitudes of clients in the under 25 year old age group about Chlamydia infection

-consultation styles of pharmacists

-how sexual health advice is given and received in pharmacies and whether it leads to behaviour change

- clients' attitudes and beliefs of self-administered Chlamydia tests.

A test that can be transported to the laboratory by post is needed for males. We understand that this is being developed and may be available within the next two months.

It is also our belief that a better method of evaluating the service is required.

At present, pharmacists have been requested to continue offering the Chlamydia test service to clients until instruction is given by PCT’s on the future scope of the service within the whole primary care sexual health strategy.

Acknowledgements

Thanks are due to the CASPHER team, LPC and PCT staff who assisted in the implementation of this pilot and the finance staff at Health House who provided information. Thanks also to PSNC for the financial support.

Appendix 1 – Standard Operating Procedure (version 1) Pharmacy Chlamydia testing.

Purpose
To ensure all appropriate patients are offered a test
To ensure that appropriate counselling and advice is provided to patients
To ensure paperwork is completed fully
To ensure all necessary records and claims are made
Scope
Inclusion Criteria
Women aged between 16 and 24
Under 16 year old women should be considered competent to give informed consent by the pharmacist (Gillick Competence)
Exclusion Criteria
(These clients will be referred to Family Planning or GUM clinics)
Men
Women aged 25 or older
Women who are not competent to give informed consent
Clients with symptoms
Responsibility
The parts of the process marked in blue italics could be completed prior to the consultation
The pharmacist is responsible for providing the service to patients and keeping any necessary records.
Processing of claims, maintaining sufficient stocks of leaflets etc., and preparation of records may be delegated to a member of suitably trained staff at the pharmacist’s discretion.
Additional Information
Known Risks
Clients under 16 (ensure Gillick competence before supply)
Clients presenting when trained pharmacist is not available
References
CASPHER team Tel: 01482 336397
Hilary Edmondson Tel: 01482 502882/335823
List of other pharmacy sites offering Chlamydia Tests (in folder)
Audit
Feedback will be provided by the CASPHER team after the 6 month pilot phase
Review
In the event of staff changes
In the event of any critical incidents
In the absence of the above
On or before the date shown below (end of 6 month pilot)
Version 1 Prepared by / J Peacham
Implemented at the Pharmacy site by
Signature
Date of preparation / 20th January 2005
Date effective from
Version number / V1.1
Date of review / April 1st 2005

I have read the standard operating procedure for the Pharmacy Chlamydia Testing Scheme and understand its implications

Name of staff member / Signature / Date
Process
1 / Display poster in the pharmacy offering free test to under 25’s
Ensure sufficient stocks of leaflets, record forms, swabs etc. at all times
2 / Offer test to all females aged 13-24 attending for EHC or self referring into the scheme
3 / Discuss test with patient
Chlamydia is the most commonly diagnosed STI
Our area has highest rate of infection after London
Very worrying for young people as there are usually no symptoms but it may lead to complications/infertility in the future
We can fill in the paperwork here
The test is a simple swab test which you can do at home/in private
If you are positive the treatment is easy (single dose antibiotic)
4 / If the patient accepts the test move onto step 5.
If they decline the test provide them with a leaflet and explain that they can return to the pharmacy or contact CASPHER for a test another time.
5 / Attach Sticker to top sheet (Information)
Detach information sheet and give to client.
Explain that the sticker has their personal number which identifies them if they contact CASPER
6 / Attach Sticker to 2nd sheet (Patient details)
Screening centre = 5E6DA
7 / Complete patient details and DOB
Tick female
8 / Complete contact details
Explain that they will only be contacted if the result is positive
The message will be discrete e.g., “Please call the office on 336397”
If they have not heard from CASPHER after 2 weeks and require reassurance they can call the office
9 / Check the patient does not have any symptoms of STI (leave blank)
10 / Tick test offer accepted
Explain that they will test for Gonorrhoea if they receive a positive test for Chlamydia (Tick if accepted)
11 / Tick reason (contraception?)
Ask for other optional information and mark Yes/No/Decline
Tear off end strip
12 / Attach sticker to 3rd Sheet (Virology)
Hospital/ward/clinic/GP = Pharmacy
Clinic Code = 5EGDA
13 / Tick female
Complete patient details and DOB.
14 / Complete date collected
Tick vulval/vaginal swab
Screening centre = “pharmacy”
Tick screening
Tick programme only
15 / Tick self swab room temperature
Tick test for gonorrhoea accepted/declined
Record if antibiotics taken in the last month (add name of medication if known)
16 / Attach sticker to pharmacy log sheet (Spare)
Transfer patient contact details and DOB
17 / Give swab to patient with explanation sheet
Explain how to perform test (use demonstration swab)
Explain that they need to attach a sticker to swab container before putting it in the plastic bag
Explain how to seal the bag and that it should be sealed in the padded envelope and posted as normal via royal mail
18 / Ensure patient receives a bag containing:- Their completed screening form
Swab and explanation sheet
Information sheet + CASPHER leaflet
Stamped addressed padded envelope
Evaluation form
19 / Check understanding/ask if patient has any questions
Advise that they can contact the pharmacy or CASPHER if they have any queries
20 / Photocopy the log sheet at the end of each month.
Keep one copy in the pharmacy and send one copy to CASPHER
21 / Claim for the number of tests provided at the end of each month (box on EHC claim form)