There is a clear value from pharmacist involvement in supplying ehc but commissioners need to start paying properly for the service, writes Terry Maguire
Accusations of profiteering by Boots were in the newspapers in December. That old chestnut, the retail price of Emergency Hormonal Contraception (EHC), is never far off the pages of the British liberal dailies. I was personally horrified that Boots would do such a thing; supply EHC so cheaply. I do cringe at the sales promotions of medicines generally, and Boots were really asking for trouble when they offered EHC as a Black Friday deal for £8.00. Bringing the price back to £15.99 after that American-themed retail-fest was going to hurt the bleeding hearts, especially when other caring UK pharmacies, such as the wonderfully-named Chemist4U, dish it out at £3.39.
I’m somewhat worried by all this, since I remain committed to the original retail price of £25, which justifiably contains a profit margin and a professional fee for my input. Of the 10 sales I do a month, it’s not my retirement fund, but it makes up for the poor margins on most of my frontof-shop. And I engage to earn my fee, but that engagement is now in question, which is interesting if not ironic.
Boots’s normal EHC price was attacked as a “sexist surcharge” by the British Pregnancy Advisory Service (BPAS), the UK’s largest abortion provider, and they told The Independent newspaper that emergency contraception should be free. I agree, and it is free within the NHS from GPs, A&E and sexual health clinics, but not commissioned in many pharmacies across the four UK nations. We had a successful pilot in my area some years ago and there are now plans to commission an EHC service as part of Pharmacy First across N Ireland.
Pharmacy First allows the public to visit the pharmacy first, and hopefully, when there, to get the advice, support and medicines they need on common and self-limiting conditions without having to go to the GP. This was one of those proposals that had been a good idea but never got commissioned, and then there was Covid.
When Covid-19 hit, GPs disappeared deep into their bunkers and their reception staff took up sniper positions should anyone have the temerity to approach the surgery door; the need for a Pharmacy First service has never been more acute or obvious.
Self-care has been a key UK government policy since the Blair-Brown years. Self-care is, as it states, care by patients themselves or their carers. Theory is that there will be huge efficiencies for the health service if patients take more care of themselves and the logic is that highly-accessible community pharmacy could take on a large chunk of this work, allowing GPs and A&Es to focus on more seriously ill patients. It hasn’t worked to date, for two reasons.
The service has been poorly funded and badly designed, with its focus on supply of medicines as an outcome of the intervention and of course, there is the issue of trust. For health commissioners, there perhaps remains concern that self-care services focused on community pharmacy might just see more OTC medicines ending up unused in home medicines cabinets while patients continue to visit the GP and A&E anyway. Ten years ago, our first Minor Ailments Scheme was abruptly modified due to abuse.
Certain multiple pharmacies, for example, imposed quotas on pharmacy managers to maximise profits from the scheme. This was irritating for most of us who kept to the rules and the spirit of the service. The Health Board should have directly challenged this excess. A strict letter to the responsible pharmacist would have provided cover against rapacious senior management, but the choice was to crash the scheme through lack of trust.
But now with the challenges of providing a health service in a post-Covid-19 world, Pharmacy First is back on the agenda and EHC will be one of the first commissioned services. It will be up to negotiators to determine the fees paid to contractors, but the scheme is likely to be for a defined age group, such as women between 16 years and 25 years. This would mean pharmacies supplying EHC; on a GP’s prescription, in the Pharmacy First Scheme, and OTC by counter sales.
The switch of EHC from POM to P was an unqualified success and the role of the pharmacist was central to ensuring the safe use of this medicine — so much so that, ironically, there are now calls for the product to become a General Sales List medicine, where it can be sold in any retail outlet. There will be dangers if the pharmacist is cut out of the supply of EHC and ironically, these are the very dangers highlighted by the bodies, like the consumer-vigilant BPSA, that initially opposed the OTC supply of EHC when MHRA first considered the switch because they deemed it too dangerous.
The safety profile of EHC and the public health gain from its use is down to its supply by pharmacists. If women struggle to get emergency contraception, that leads to unplanned pregnancy, and that leads to more women seeking an abortion, and that is not a good thing. No woman aspires to have an abortion. And of course there are wider issues, such as information and advice on safe sex and STDs, as well as watching out for sexual abuse.
So is the role of the pharmacist in the supply of EHC of any value? If so, what is this value and what can be justified as fair recompense? Seems the public are indifferent to our role as we retain our position in a twilight zone, being commercial retailers and professional practitioners. Recently, a good friend was livid when his wife had her smile improved by an orthodontist for a price tag of £10k. My friend, no stranger to wheeling and dealing in the property business, met with the super-dentist to negotiate, and having offered a deal for cash, a promise to send more clients and a plea to the sanity of his invoice, the dentist calmly confirmed the £10k fee and expressed disappointment that his professionalism was being challenged. Okay, that’s perhaps a different ball-park, but the principle stands.
Access to UK contraceptive services such as EHC was disrupted by the Covid-19 crisis and there have been funding issues affecting public health services generally that predate the pandemic. The pandemic shut or reduced clinics, while staff were transferred to work with Covid-19 patients or forced to self-isolate. There is a clear value from pharmacist involvement in the supply of EHC, so health commissioners need to start paying for an EHC service and the ongoing sniping by consumer groups about the costs of our products needs to stop.
Terry Maguire owns two pharmacies in Belfast. He is an honorary senior lecturer at the School of Pharmacy, Queen’s University Belfast. His research interests include the contribution of community pharmacy to improving public health.