Safe and sound

Figures show that people are now less likely to access dedicated sexual health services than they used to be. Pharmacy staff can play an important role in helping to fill the information void

With so much pressure on GP surgeries, it would seem logical that other places that offer some of the same services would be getting busier. But when it comes to sexual health, this just isn’t happening.

While it may be easier to get contraception from a local genitourinary medicine (GUM) clinic than it is to get an appointment at an overloaded doctor’s surgery, figures released in October by NHS Digital show a four per cent year-on-year drop in the number of contacts made by men and women with sexual and reproductive health services. A significant proportion of the decline was due to a fall in visits from younger age groups, as well as reduced demand for the contraceptive pill and male condoms.

Stretched to the limit

Laura Russell, senior policy and public affairs officer for sexual health charity FPA, says: “It is really hard to say why the number has gone down. It could be due to more people using long-acting reversible contraception (LARC) like the implant, injection or intrauterine device or system, which would mean longer times in between visits, or it could mean that they are accessing services elsewhere, such as at their GP surgery.”

However, Laura is concerned that services are being shut down, moved or restricted because NHS organisations and local authorities are “struggling to make ends meet”.

This concern is echoed by Private Lives, Public Health, a report published towards the end of 2016 by the Advisory Group on Contraception, which stated: “The delivery of contraceptive care in England is understood to be under acute and growing pressure, largely due to significant cuts in local authority budgets and pressure on general practice capacity and funding.” 

The report also noted that more than one in six authorities had decreased spending on contraceptive services during the financial year 2015/16; one in seven councils had closed sites in 2016 or were planning to do so in 2016/17, and another 13 per cent said that they were considering doing the same.

Private Lives, Public Health pulled no punches in describing the ramifications of all of these closures. “While progress has been made over the past decade in reducing the number of abortions and teenage pregnancies,” it stated, “it will not take long for that progress to reverse if women of all ages cannot access the contraceptive options they want and need. This is particularly pressing in light of recent abortion statistics, which show an increase in the number of older women requiring abortion services.” 

Laura believes that people in vulnerable groups, such as those who cannot travel, are more likely to be affected by cuts to services, but adds that lots of people don’t know where and how to access information and services on sexual health and contraception. “Community pharmacy has an important role to play in providing advice and signposting and reassuring anyone who might be anxious about going to a sexual health clinic that their confidentiality will be maintained and, generally, it is going to be OK,” she says.

A new approach to HIV

The best way to avoid HIV, the virus that attacks the immune system and can develop into AIDS, is never to have sex without a condom, and never to share needles and other injecting equipment. But a new approach to preventing the spread of the virus is now being trialled. 

PrEP (pre-exposure prophylaxis) involves taking anti-retroviral drugs – the medicines used as lifelong treatment for HIV – to stop the virus taking hold in the body. NHS England and Public Health England (PHE) announced at the end of 2016 the launch of a large-scale clinical trial that will inform a full roll-out of the therapy. At least 10,000 participants will be involved in the project, which is expected to cost as much as £10 million.

PHE’s health and wellbeing director Kevin Fenton explains: “Currently 13,500 people are living in the UK with undiagnosed HIV and we are still seeing around 5,000 new infections each year. Given that we are in the fourth decade of this epidemic, there are too many new infections occurring and we need to use all tools available to save lives and money.”

Lucy Hedley, education, training and conference lead for the HIV Pharmacy Association, believes that the high cost and monitoring of PrEP means that these drugs will likely only be given out in hospitals and sexual health clinics. But she says that when people in this patient group do visit community pharmacies, there are a few key points that staff need to keep in mind. “Be aware that drugs for HIV – and also those used on a short-term basis for hepatitis C – have a lot of drug interactions, including with some common OTC ingredients – for example, fluticasone and omeprazole,” she says. “Refer these patients to the pharmacist, who can check on the University of Liverpool HIV and Hep C Drug Interactions websites (hiv-druginteractions.org and hep-druginteractions.org), which uses an easy-to-understand traffic light system. However, care should be taken with interpretation of amber interactions and these should be referred back to the specialist HIV or hepatitis unit.”

Seize the moment

The key to pharmacy teams helping people with sexual and reproductive health needs is approachability, says Jess Follows, learning and development partner at Celesio, the parent company of LloydsPharmacy. “Support staff are on the front line, so they deal with whatever and whoever walks in the door,” she says. “Basic customer service skills underpin everything: greeting people with a smile, saying hello and asking ‘Is there anything I can help you with today?’.

“Getting the basics right means you build rapport with customers, which means someone is more likely to ask for advice or information. When it comes to sexual health and contraception, remember that the customer may be embarrassed. Be sympathetic; offer to speak to them in the consultation room or a quiet area of the pharmacy. It’s about providing a safe, professional healthcare environment and showing that you are completely comfortable and want to do the best for your customers, regardless of what the issue or condition is.”

Jess continues: “If the service the customer wants isn’t available, make sure you can signpost the person to somewhere where it is. Have a folder to hand of what is available where, and make sure it is kept up to date, including details of where to go at weekends, late nights and early mornings. Remember that the person may be anxious or nervous and time may be pressing – if they have come in for emergency contraception, for example – so offer to phone and book an appointment rather than saying ‘It’s just down the road.’”

The bigger picture

“Think of patients holistically,” Jess advises. “What else can be done to help the patient in their everyday life? For instance, a patient might mention that they find it difficult to get to the GP to pick up prescriptions for their contraceptive pill. Would a long-acting contraceptive method be better for that individual? If someone is buying condoms, do they know what is available locally in terms of STI testing? Pharmacy is increasingly focused on healthy lifestyles and sexual health is a big, but often overlooked, part of that.”

Laura warns to not make assumptions about what people know. “Sexual health education is very patchy,” she says. “The content of the national curriculum on the topic, particularly at secondary level, is limited, and many schools, such as free schools and academies, don’t have to follow the national curriculum.” 

It’s also a mistake to focus your attention solely on women, says Laura. “While it is true that contraception often falls to females,” she explains, “methods other than barriers don’t offer protection against sexually transmitted infections. Think about sexual health as well as reproductive health.”

The Private Lives, Public Health report sums up the importance of contraception options when it says: “Access to and choice from the full range of contraception methods is a fundamental right for all women, regardless of age. It is mandated in legislation and is essential to delivering the sustainability of the NHS in the long term… Progress has been made over the last decade in reducing abortion rates and teenage pregnancy rates [and we] must work together to ensure that this progress continues, ensuring better outcomes for woman of all ages. If we go backwards, women, their families and society will pay a high price.”

Be ready to advise about the full range of contraception
methods, including the pill and condoms

Safeguarding awareness

All pharmacy staff should have an awareness of safeguarding – it’s not just the domain of the pharmacist or manager. 

The term ‘safeguarding’ refers to the protection of people’s health, wellbeing and human rights so that they are able to live free from harm, abuse and neglect. It applies to adults as well as children, and is everybody’s responsibility. All pharmacies should have specific safeguarding policies and procedures in place.

The Centre for Pharmacy Postgraduate Education (CPPE) has developed an e-learning programme on the topic, completion of which fulfils the contractual safeguarding requirements at Level 2 for pharmacists and pharmacy technicians, and allows support staff to prove competence at Level 1. Staff in Wales can access WCPPE materials. Resources are also available from the National Pharmacy Association.

In an emergency

Emergency contraception (EC) is an area that pharmacy has been involved in for many years, and it used to be quite straightforward: with just one product available OTC (levonorgestrel), all the pharmacist had to do was check whether it was suitable, and signpost the customer to other services if it wasn’t. But the waters have got a little more muddied recently, with the introduction of a new morning after pill option.

How do the two morning after pills differ? Well, one – the long-established product – contains levonorgestrel and is sometimes referred to as LNG-EC, whereas the newer option contains ulipristal and is known as UPA-EC. There are significant differences between the two, as summed up by the influential Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists in draft guidance on emergency contraception that is due to be published later this year:

  • UPA-EC has been shown to be effective for up to 120 hours after UPSI, whereas LNG-EC is only licensed for use up to 72 hours after unprotected sexual intercourse.

The draft guidance also provides information on other forms of EC, such as the copper IUD. The guidance states:

  • The copper IUD (Cu-IUD) is the most effective method of emergency contraception and can be fitted up to five days after unprotected sexual intercourse
  • Information on all methods of EC should be provided, regardless of whether or not they can be supplied, and signposting provided if necessary. If a woman is referred for a Cu-IUD, oral EC should be given in case the woman changes her mind about the IUD or it turns out to be unsuitable
  • Enzyme-inducing medicines can reduce the effectiveness of UPA-EC and LNG-EC, and a Cu-IUD is often a better option. The effectiveness of UPA-EC can be reduced by medicines that raise gastric pH, or if a progestogen-containing product is taken beforehand or in the five days afterwards
  • Unlike the Cu-IUD, oral EC does not provide ongoing contraception.

It is worth thinking about what the experience of obtaining EC through pharmacy is like. Nobody involved in the consultation is likely to think of it as just another OTC product, but the encounter may well dictate whether the customer comes back to the pharmacy in the future. Put yourself in her shoes, or consider how you would want it to be for your sister, daughter or friend, and make it non-judgmental, empathetic, supportive and confident. The need for privacy and confidentiality is paramount, but be aware that while there is much to run through, taking too much time may be off-putting or even downright distressing.

Pharmacy is increasingly focused on healthy lifestyles, and sexual health is a big, but often overlooked, part of that

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