cpd module

THE
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CONTINUING

PROFESSIONAL
DEVELOPMENT
PROGRAMME

This module has been accredited by the College of Pharmacy Practice as suitable for use by pharmacists as part of their continuing
professional development cycle. Complete the record form on page viii for inclusion in your CPD portfolio

CURRENT THINKING ON...

MODULE

154 PROVIDING A SEXUAL

Welcome to the one hundred and fifty fourth module

in the Pharmacy Magazine Continuing Professional
Development programme, which looks at providing a
sexual health service. It is valid until July 2011.
Continuing professional development (CPD) is an
ethical and professional requirement for pharmacists
and will soon be mandatory. Journal-based educational
programmes (unscheduled learning) are an important
means of keeping up-to-date with clinical and
professional developments and form a significant
contribution to your CPD.
Before reading the module, assess your learning
needs by answering the questions below. After reading
the module, complete the record form on page viii for
inclusion in your CPD portfolio. You can also test your
knowledge by answering the multiple choice questions
and sending your answers to the address shown.
A 3.75 marking charge applies to each module.

Self-assess your learning needs:

What additional skills, facilities and equipment
would I need to initiate an oral contraceptive
supply service in my community pharmacy?
What is the current service provision in sexual
health in my PCT?
What training would I need to provide for my
staff to support this service?
This module supports the following CPD
competences: C1a, C1c, C1f, C1i, C4g, C5c.
More details on pvii

FOR THIS MODULE

HEALTH SERVICE
Contributing author: Kate Kinsey, BPharm, senior commissioning
manager, primary care commissioning, Manchester PCT
Introduction
The UK has the highest teenage pregnancy
rate in Europe and the US the highest rate of
teenage pregnancy in the western world. It is
10 years since the Governments Our Healthier
Nation white paper made teenage pregnancy in
this country a priority target for health
authorities with high teenage conception rates.
The Social Exclusion Report 1999 set targets
for local authorities to halve teenage pregnancy
rates by the year 2010 and to establish a
downward trend in the rate among under-16s.
This is coupled with the strategy to increase the
proportion of teenage parents in education,
training or employment to 60 per cent by 2010
and hence reduce their risk of long-term social
exclusion.
All local areas have a 10-year strategy in
place with under-18s conception rate reduction

targets of between 40-60 per cent. These local

targets underpin the national target of 50
per cent.
Reduction in teenage pregnancy is sometimes
seen as a political issue but there are important
adverse effects on both health and social factors
(see Table 1).
Community pharmacists across the country
have made a significant contribution to the
access and provision of emergency hormonal
contraception (EHC) and screening for sexually
transmitted diseases. Prior to these services
being introduced there was some scepticism
about whether pharmacies were suitable places
to provide EHC. However pharmacy-based EHC
services are not only regarded as highly
successful but there is now recognition of the
significant contribution that can be made to the
further development of contraceptive services by

GOAL:

To explore the role that community pharmacy can play in providing

a comprehensive sexual health service to women of childbearing age.

OBJECTIVES:

After studying this module, you should be able to:

Describe what is entailed in providing contraception, and chlamydia
advice and screening services
Explain how pharmacy-based sexual health services can contribute
to reducing the incidence of unwanted pregnancy
Prepare an action plan to introduce (or revise) a sexual health service.

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allowing pharmacists to provide regular

hormonal contraception.
In December 2007, in a statement to the
House of Lords, health minister Lord Darzi
stated that we recognise that pharmacies could
play an increased role in the provision of
contraception and other sexual health services
because of their accessibility and convenient
opening hours. We will work with primary care
trusts over the next year to pilot the supply of
contraception, including the contraceptive pill,
through NHS arrangements. We will also work
with the pharmacy profession to ensure robust
standard setting and appropriate training so
that pharmacists are competent to provide
this service.
The recent pharmacy white paper
acknowledges the input that community
pharmacists have already made in sexual
healthcare; in particular, the role of pharmacists
in the provision of EHC and chlamydia
screening. This was again reflected in the
Department of Healths latest primary and
community care strategy, published last month.
An independent evaluation of a pilot
chlamydia screening service available across
London since November 2005 has shown that
87 per cent of young people would recommend
the service. Based on this evaluation the
Government intends to publish a national
template to support primary care trusts
commissioning of chlamydia screening from
community pharmacies as part of the National
Chlamydia Screening Programme. (Source:
Pharmacy in England, Building on Strengths
Delivering the Future; Department of Health,
April 2008.)

Manchester Primary Care Trust for the provision

of a sexual health service, centred on a patient
group direction (PGD), by community
pharmacists. The service is the first in the UK
in which pharmacists are initiating oral
contraceptive supply and provides a model for
future services.
The Manchester pilot involves accredited
community pharmacists providing advice,
supply and follow-up to women who wish to
access a family planning service. The
pharmacists are able to supply either condoms
or a hormonal method of contraception
(combined oral contraceptive pill [COC] or
progestogen-only pill [POP]), or can offer advice
and possible referral to other agencies where
appropriate.
In addition the project allows pharmacists
to access the chlamydia screening programme
for women under 25 years of age or for any
women who wish to access the service should
the need arise. The project also allows
pharmacists to test and treat a woman (and
her partner if appropriate) presenting with a
positive result for chlamydia under a PGD.
The purpose of the service is two-fold:
To give women greater choice and flexibility
in accessing services
To reduce teenage conception rates.

will be commissioned taking into account

identified local needs. The Manchester Teenage
Pregnancy Partnership (MTPP) published a
report that identified 17 wards across the city
where the rate of teenage pregnancy and
termination was higher than 60 per 1,000
women. In addition, due to the high student
population of the city, a further ward was
included in the pharmacy service to address the
needs of the student population resident during
the academic year.
These areas of greatest need were targeted
through the new pharmacy service. Community
pharmacists already experienced in providing
the existing EHC scheme under a PGD were
invited to become providers of the new service
and received training to achieve the necessary
accreditation.

Commissioning pharmacy-based sexual health

services

Service delivery

Practice points
Consider whether your pharmacy is in an area
of greatest need for sexual health services and
whether you should approach your PCT with a
view to providing a service.
Do you already provide EHC under a PGD? If so,
you will have already undergone role-play activities
as part of your accreditation. Also, the experience
gained providing consultations for an EHC PGD
service is invaluable.

Table 1: Health and social consequences of teenage pregnancy

In order to provide a sexual health service, a

number of factors need to be taken into
consideration:
Premises
Service access
Staff
Equipment
The consultation (including medical history)
Records/paperwork
Training
Service audit.
Each of these will now be considered in turn.

Children of teenage mothers:

Premises

Manchester initiative
This CPD module is able to draw on the
experience of the pilot project developed by

Community pharmacists in Manchester had

already been supplying EHC under a patient
group direction since 1999. The scheme has
been very successful with over 150,000 women
accessing the service in that period of time.
Many primary care organisations, including
Manchester, now commission this as an
enhanced service under the pharmacy contract.
Any pharmacy-based sexual health service

Have higher rates of infant mortality than children born to older mothers
Are more likely to be born premature which has serious implications for long-term health and have
higher rates of admissions to A&E
In the longer term, experience lower educational attainment and are at higher risk of economic inactivity
as adults
The pressures of early parenthood result in teenage mothers experiencing high rates of poor emotional health
and wellbeing which impacts on their childrens behaviour and achievement
Teenage mothers often do not achieve the qualifications they need to progress into further education and,
in some cases, have difficulties finding childcare and other support they need to participate in education,
employment or training. Consequently, they struggle to compete in an increasingly high-skill labour market
Teenage mothers and young fathers disproportionately come from disadvantaged backgrounds and are
more likely to need additional support to make a successful transition to adulthood. Becoming a teenage
parent adds significantly to the challenges they face.
It is estimated that three-quarters of under-18 conceptions are unplanned and around half end in abortion.
It is important therefore that there is a strong focus on preventing teenage pregnancies. Steady progress has
been made on reducing the under-18 conception rate, which has fallen by 11.8 per cent (based on 2005 data)
since 1998, to its lowest level for over 20 years. Within this overall reduction in conceptions, the rate of births
has fallen by almost 19 per cent, whilst the rate of abortions has fallen by almost three per cent.

Since the launch of the pharmacy contract in

England and Wales in 2005, most community
pharmacies now have a consultation room. This

Source: DH Teenage Parents Next Steps: Guidance for Local Authorities and Primary Care Trusts 2007

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cpd module
is an essential element for sexual health services
due to the length of a typical consultation. The
average time for an EHC consultation using a
PGD is around 10-15 minutes. The new service
needs a longer period for the initial consultation
and also requires storage of confidential
paperwork and some equipment (see later).

Practice point
How would you manage your consultations for a
contraception service in respect of other services
you may be providing, such as MURs or supervised
methadone consumption?

Service access
Part of the consultation process for the
Manchester EHC service requires pharmacists
to discuss future contraception. This is one
access point for the new contraceptive service.
Other access points that could be explored to
encourage women to access the service include:
Emergency supplies of oral contraceptives
Current contraceptive service provision,
which may be poor in your area
Current contraceptive service provision that
is not easily accessible
The local GP practice may not have the
capacity to provide this service. Your local
surgery may wish to refer women directly to you
The longer opening hours, including
weekends, of a pharmacy providing a sexual
health service.

Support staff
As with setting up any new service, you should
consult your pharmacy staff first. You need to
consider how:
Staff should deal with women wanting to
access the service and how this information is
relayed to you
The service will remain available during
sickness and holiday periods.
Locums must also be consulted. Whether a
pharmacy uses a regular locum or someone
from an agency, they must be able to access the
required training.
Consideration should also be given to the

Pharmacists and support staff are to play an expanded role in providing sexual health services
length of time for a consultation. If the pharmacy
is busy at certain times, then you may wish to
direct staff to operate an appointments system.
How will this be managed? Will you issue
appointment cards?

Weighing scales
BMI chart
Height chart
Paperwork.
The PCT may provide this equipment for you
or you may have to purchase it separately.

Practice point
How would you approach your regular locum/s
so they can engage with this service?

Practice point
Do you have agreements so pharmacy equipment
can be serviced regularly?

Equipment
In order to decide whether to supply oral
contraception pharmacists are expected to
undertake a number of health checks, which
require the following equipment to be available:
BP monitor

Consultation
It may be difficult to determine the length of
the consultation but you should allow yourself
at least 30 minutes to complete all the necessary
checks and assess the patient history. It is also

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Sexual history
First day of last period.

Inclusion and exclusion criteria

Inclusion criteria:
Have other methods of contraception been
discussed, including long-acting reversible
contraception?
Does the client have regular periods?
Was the last period normal?
If under 16 years of age, does the client meet
the Fraser Guidelines? Is the client competent to
consent to treatment?

Pharmacist-initiated supply of hormonal contraception is being piloted in Manchester

dependant on how the client accessed the
service (e.g. via an EHC consultation or referral
from another healthcare professional). Another
important factor to consider is whether this is
a first supply of hormonal contraception or a
repeat supply.
The Manchester scheme uses the same
protocol for the supply of a POP or COC but
has a different protocol for initial and repeat
supplies. The crucial difference between the
protocols is establishing where and when the
first supply of contraceptive was initiated. If
supply has been within 12 months from the
pharmacy, then the repeat procedure is followed.
However if the supply was longer than 12
months ago, the pharmacist is advised to use the
first issue protocol to ensure that the client
receives the most appropriate advice and care.
If the client has accessed contraception from
another agency in the past, the pharmacist is
responsible for ensuring that all the appropriate

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checks and advice have been undertaken during

the pharmacy consultation.

Medical history
The most important aspect of a pharmacybased sexual health service is ensuring that an
accurate medical history is taken from the client.
This history, together with any measurements
that are recorded (including blood pressure,
weight, height, BMI) will inform the decision
about the type of contraception that should be
considered. The guide to the typical sexual
health consultation provided below is based on
the Manchester scheme.

Client history
Name
Date of birth
Address
GP (including practice details)
Ethnicity.

Exclusion criteria:
Does the client have a known intolerance to
oestrogen or progestogen?
Is the client pregnant?
Does the client have any unexplained vaginal
bleeding?
Does the client have active liver disease, cholestatic jaundice or a history of jaundice in pregnancy?
Is there a history of migraine?
Has the client had recent trophoblastic
disease? (This question could be asked as:
Are you undergoing any treatment for a
complication of a previous pregnancy?)
[Trophoblastic disease is an uncommon
complication of pregnancy where there is an
abnormal overgrowth of all or part of the
placenta causing a condition called a molar
pregnancy. It is detected by a rapid rise in the
levels of human chorionic gonadotrophin (hCG).
It is recommended that patients should not use
either oral contraceptives or an IUD during
treatment or for some time after to ensure that
the levels of hCG do not rise and lead to
confusion. Women are normally registered with
regional centres for ongoing treatment.]
Does the client have heart disease or a history
of stroke?
Does the client have malabsorption
syndrome? (This question could be asked as:
Are you aware that you have a condition such
as coeliac disease or anything that might affect
you being able to absorb certain foods?)
Does the client have cancer or a history of
breast cancer?

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Is the client receiving concomitant medication
that interacts with oestrogen or progestogen?

Information needed
Blood pressure (BP >140/90mmHg = POP
[progestogen-only pill]; a combined oral
contraceptive would not be considered
appropriate for this patient)
Weight (kg)
Height (cm)
BMI (BMI >35 = POP)
Smoking status (>35 years, smoker = POP).
NB. If the client is an ex-smoker the date when
she gave up should be recorded including the
average number of cigarettes smoked per day.
If it is less than one year since she gave up, she
should be treated as a smoker and counselled
that the most appropriate form of hormonal
contraception is a POP.

Deciding which form of contraception

is appropriate
All of the preceding information should be
collected prior to a discussion with the client
about the different forms of contraception
available. The answers to the questions will
inform the clinical decision as to which form of
hormonal contraception (if any) would be
suitable for a client. You would then need to
consider specific exclusion criteria for the
combined oral contraceptive (COC) pill.

Practice point
What other factors should be considered?

Does the client have complicated diabetes

(e.g. nephropathy, retinopathy or neuropathy)?
Is there a family history of venous
thromboembolism (VTE), myocardial infarction
(MI) or cerebrovascular accident (CVA) in a first
degree relative under 45 years old
Is there a history of:
transient ischaemic attack?
systemic lupus erythematosus (SLE) or
lupus anticoagulant disorder?
acute porphyria or long-term immobility?
Does the client have current or past VTE or
clotting tendency?
Is there a known presence of gallstones?
If the client is suitable for a COC, proceed to
the Counselling section below.

COC exclusion criteria

Is the client less than six weeks post partum or
breast-feeding?

Practice point
If the client is not suitable for a COC, what would
be your next course of action?

POP exclusion criteria

Does the client have a current VTE or acute
porphyria?
If the answer to this question is yes, then the
client should be referred to a family planning
clinic or her GP. If the client is suitable for a POP,
refer to the Counselling section below.
If the client is not suitable for either form
of hormonal contraception, this should be
documented and the person referred to another
healthcare professional.

Practice point
Think about how you would tell a client that
she is not suitable for either form of hormonal
contraception. Be aware of the other forms of
contraception available because the client may
ask for further guidance.

Counselling

Blood pressure is a key determinant in the choice of oral contraceptive supplied

If the client is suitable for one of the hormonal

methods of contraception, you should provide
the following counselling, which must be
documented each time.
Efficacy

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Mode of action
Effect on menstrual cycle/bleeding
Risk and side-effects, breast tenderness,
headache, VTE risk
Starting regimen
Vomiting and diarrhoea (and what action
to take)
Enzyme inducing medication
Missed pill advice
Safer sex guidance
Smoking/alcohol advice
Action if side-effects or concerns
Discussion of emergency contraception
Contraception leaflet given
Condoms given
Follow-up appointment.
It is important to ensure that you are able to
supply a range of literature to help with
counselling, such as the Department of Health
leaflet on different forms of contraception
as well as information on sexually transmitted
diseases.

Practice point
Do you already stock this information? If not,
do you know where to obtain supplies? The
local PCT may be able to provide advice and
support for this.

Records and paperwork

Your PCT would, in all probability, provide the
necessary paperwork for audit purposes.
However you may need to consider what
information you should record in order to
provide the appropriate advice and supply.
In addition to the information obtained

during history-taking and counselling, the

following information should be recorded
by the pharmacist to complete the consultation:
Brand of contraceptive provided (you should
be confident that you have supplied all of the
relevant information for the client to make an
informed choice)
Batch number and expiry date
Prescription length (e.g. three or six months)
Date of review.
The PCT may require that information
regarding the supply is sent to the clients regular
GP. However patient consent must be obtained
before this can occur. The client and pharmacist
should sign and date the paperwork to complete
the audit trail.

Practice point
How would you approach a refusal by a client for
this information to be supplied to their GP?

An audit form should be completed for the

PCT and all documentation stored following
Caldicott Principles, preferably in alphabetical
order.

Training
In order to be commissioned to provide the
Manchester service, community pharmacists
must fulfil the following criteria:
Be accredited to provide EHC
Undergo further training and accreditation for
the new service
Undergo enhanced criminal record checks
Be working in wards identified by the
Manchester Teenage Pregnancy Partnership as

areas with high teenage pregnancy rates

Be prepared to commit to providing the
service at the pharmacy for a period of time
Be working in a pharmacy that has a
consultation room of the standard required for
accreditation under the advanced service tier of
the pharmacy contract.
The pharmacists receive additional training
delivered by a consultant in sexual health or
similarly qualified clinician, such as a GP with a
special interest in sexual health. The supply of
hormonal contraception is made under a PGD.
The training covers:
The PGDs for the different types of
contraceptive pills i.e. COCs and POPs
Chlamydia testing and the PGDs for treatment including azithromycin, doxycycline and
erythromycin
Inclusion and exclusion criteria
Referral pathways
Paperwork
Child protection
Education in sexually transmitted infections
How to complete the relevant health checks
(i.e. height, weight, calculation of BMI and BP)
Role-play exercises
Multiple choice questions.
In order to reduce the paperwork, Manchester
PCT provided pharmacists with a CD-ROM of
the relevant research papers and guidance, and
each pharmacy was given a copy of the

Practice point
Think about the different brands of COCs and POPs
available. Do you feel confident enough to discuss
them all with your client? Remember a client may
have used a particular brand before so you must
check what, if any, hormonal contraception has
already been used. The PCT may specify which
brands are to be supplied.

Tackling teenage pregnancy remains a key public health priority

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publication, Family Planning: A Global
Handbook for Providers 2007, which is
produced by the World Health Organization.

Service audit
The Manchester service will be evaluated by
the PCT after six months, which will collect the
following information for audit purposes:
The number of women accessing the service
Age
Postcode
Method of access
Type of contraception supplied
Length of consultation
The number of women who:
Have been referred to other services
Fall outside the protocol
Are receiving contraception for the first time
Are receiving repeat contraception.
Post-payment verification checks are to be
carried out six months after the service has
commenced, together with a patient satisfaction
survey.

Experience to date
The Manchester scheme is a pilot project and
the six months evaluation will take into account
the audit information together with advice and
recommendations from the pharmacists
involved. The intention is for the pharmacists
to use the paperwork provided by the PCT for six
months, then re-evaluate to ensure that all the
necessary information has been recorded and to
determine the length of time taken for each
consultation.
The service in Manchester uses the expertise of
some of the most experienced pharmacists
already providing the EHC service. If the new
service is to be provided by a primary care
organisation that did not have such a wealth
of experience, consideration should be given to:

CPD competences
This
module supports
the 6637
following community pharmacy competences:
GlaxoSmithKline:
0845 762
Competence

Where this module supports competence development

C1a Assessing the medication

needs of patients

This module provides information on the assessments required to

ensure that a patient would receive the most appropriate contraception

C1c Reviewing medication with

patients

Reviewing medication is discussed in order to identify difficulties and

potential risk (e.g. concordance issues, adverse effects, changing
medication needs)

C1f Providing advice and

counselling

This module focuses on the information that should be provided by the

pharmacist to ensure that the patient understands how to take/use the
contraceptive supplied

C1i Generating and maintaining

records of medication supplied
to patients

Information regarding the records required for the service to be

provided and the information that would be required by a PCT for audit
purposes are outlined in the module

C4g Working across

professional boundaries

The need to consider the input and impact on other stakeholders when
setting up a sexual health service is considered

C5c Developing and

implementing new services
under local or national contracts

This module discusses the factors that need to be taken into account
in ensuring good clinical governance

Training in conducting consultations

Role-play exercises
Attending a family planning clinic to gain
experience of the service.
At present most women accessing the new
service do so via a request for EHC. As
community pharmacists become more familiar
with the project, it is expected that the number
of women accessing the service will increase.

Reflection exercise
What are your PCT targets for reducing the
teenage pregnancy rate?
Where would you find this information?
What training would you provide for your staff
in order to promote this service and ensure that
women are dealt with sensitively?

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ASSESSMENT

QUESTIONS

PHARMACY MAGAZINE CPD RECORD AUGUST 2008

USE THIS FORM TO RECORD YOUR LEARNING AND ACTION POINTS FROM THIS MODULE ON
P R O V I D I N G A S E X U A L H E A LT H S E R V I C E A N D I N C L U D E I T I N Y O U R C P D P O R T F O L I O

Activity/development completed
(Act)

P R O V I D I N G A S E X U A L H E A LT H S E R V I C E
1. Which statement is TRUE?
The COC pill increases the
risk of:
a. Breast cancer
b. Bowel cancer
c. Ovarian cancer
d. Endometrial cancer

2. Which is TRUE? Chlamydia:

a. Has higher rates in
women taking oral
contraception
b. Should be treated with
azithromycin as a firstline treatment
c. Has symptoms at the
onset of infection
d. Is commoner in women
over 25 years of age

3. Which contraceptive
choice is most appropriate?
a. A COC for a woman
who gave up smoking
six months ago
b. A COC for a woman
over 36 years of age with
a BMI of 27
c. A POP for a woman
aged over 29 years who
has not had a period
for 38 days
d. A COC for a woman
who works shifts

4. The POP pill:

a. Is the recommended
hormonal
contraception for
women who smoke
b. Is suitable for women
taking rifampicin
c. Can be taken if a
woman has migraine
headaches with aura
d. Can be supplied to a
woman who has had a
VTE in the last 6 months

5. Find the TRUE statement.

A woman:
a. Does not need her BP to
be checked with each
supply of contraception
b. Is excluded from taking
a POP if her mother had
a CVA at 44 years
c. Should always be offered
a choice of contraceptive
d. Should seek further
advice if she has
vomiting and diarrhoea
for more than 2 days

Date:

Time taken to complete activity:

What did I learn that was new?

(Evaluate)

6. During the counselling

session a woman should:
a. Be advised to have
STI screening after
unprotected sex
b. Be offered chlamydia
screening
c. Not be supplied with
condoms
d. Start any type of
contraception on the
fifth day after her period

How have I put this into practice? (Provide examples of how learning has been applied what did you do differently as a result?)
(Evaluate)

7. Find the TRUE statement.

A woman taking a COC should:
a. Take extra precautions
when taking amoxicillin
for more than 4 weeks
b. Stop if she is diagnosed
with gallbladder disease
c. Take a break from COCs
if she has been taking
them for a long time
d. Continue with it during
major surgery

Do I need to learn anything else in this area?

(Reflect)

8. The national target aims to

reduce the conception rate in
under-18s by:
a. 20 per cent
b. 30 per cent
c. 40 per cent
d. 50 per cent

If as a result of completing your evaluation you have identified another new learning objective, start a new cycle
this will enable you to start at Reflect and then go on to Plan, Act and Evaluate. This form can be photocopied to
avoid having to cut this page out of the module.

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Completed answer sheets should
be sent to Precision Direct
Marketing, Precision House, Bury
Road, Beyton, Bury St Edmunds
IP30 9PP (tel: 01284 718918;
fax: 01284 718920;
email: cpd@precisiondm.com),
together with credit/debit
card/cheque details to cover
administration costs. This
assessment will be marked and
you will be notified of your result
and sent a copy of the correct
answers. The examiners decision
is final and no
additional
correspondence
will be entered
into.

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