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The future of sexual health services

Funding cuts have imperilled sexual health services at a time of soaring demand.

Sexual health services are under intense financial pressure. The public health grant to local councils used to fund sexual health services was reduced by over £1 billion (24 per cent) between 2015/16 and 2020/21, according to figures in the Local Government Association report ‘Breaking point: Securing the future of sexual health services’, which was published at the end of 2022.

Across England, cuts to local government budgets have resulted in a reduction in spending on services such as STI testing, contraception and treatment – decreasing by almost 17 per cent between 2015/16 and 2020/21. 

Covid-19 has exacerbated inequalities with regard to accessing services such as contraception, particularly among young people, Black women and women and girls from Asian and ethnic minority groups. With many women finding it more difficult to access their chosen contraceptive methods (long-acting reversible contraception (LARC) fittings and removals have been particularly affected), the report calls for system-wide thinking and collaborative commissioning to help improve access.

Pharmacy Contraception Service

The specification for the forthcoming Pharmacy Contraception Service, including training requirements, is now available to download from the NHSBSA website. 

Alastair Buxton, director of NHS Services at PSNC, points to community pharmacy’s track record in delivering public health services, including those relating to sexual health. He says PSNC “believes that many sexual health services should be offered through all pharmacies nationally to provide consistent access across the country.”

He says the launch of the Pharmacy Contraception Service will “enable community pharmacists to provide ongoing management of routine oral contraception for women, giving people greater choice and access”. 

Mr Buxton adds: “Tier two of the service, expected to launch in the autumn, will enable community pharmacists to also initiate oral contraception.”

The funding constraints affecting sexual health services mirror the issues the community pharmacy sector has faced in recent years, says Mr Buxton. He argues that providing adequate funding to commission more pharmacy-based sexual health services “has the potential to benefit both local communities and reduce pressure on other NHS providers”.

Rising demand

Dr Claire Dewsnap, president of the British Association for Sexual Health and HIV (BASHH), says budget cuts have come at a time of soaring demand. “Overall demand for care has increased by over 15 per cent in the past year alone, surpassing pre-pandemic levels,” she says, “whilst diagnoses of certain STIs, such as syphilis, are accelerating significantly. 

“The impact of Covid-19 and, more recently, monkeypox, has placed huge additional strains upon the sexual health workforce that are not yet showing up in centrally collected data.”

Dr Dewsnap says the Government must back up its strategy with “new funding and clear, robust metrics to guide commissioning priorities,” as “failure to do so will have severe consequences for the sexual health of our nation”.

BASHH recommends working closely with specialist services and commissioners of these and community services to ensure better access. It encourages community pharmacy teams to follow its national guidance on the delivery of antibiotic provision for treatment of STIs, bearing in mind the huge risks of increasing antibiotic resistance fuelled by inappropriate and wider antibiotic use in the online setting. “We would welcome national programmes to look at how community pharmacy and sexual health services can work together to deliver appropriate treatment that is local to the service user, to improve access to care and outcomes,” says Dr Dewsnap.

“Depending on local commissioning arrangements, many pharmacies can provide a number of aspects of sexual health service free to the patient,” adds Dr Mark Lawton, a consultant in sexual health and HIV and chair of the BASHH Media Group.

NPA head of policy Helga Mangion agrees that community pharmacies are likely to play an increasing role in sexual health and contraception, possibly due to their convenience and the relative anonymity they offer. She adds: “The Women’s Health Strategy for England, launched last year, certainly envisaged an expanded role, incorporating contraception, sexual health and menopause. Sensitive and confidential conversations can take place in consultation rooms and pharmacists can provide advice and support on a product, including how to take it safely and potential side-effects.

“They also undertake appropriate safeguarding training, to identify cases of possible sexual abuse or exploitation of women and girls. More than half of the pharmacies in the UK are enrolled on the Ask for ANI scheme against domestic violence.”

Pharmacist independent prescribers may offer an important contribution, adds Ms Mangion, but she stresses that new investment will be key.

Contraception over the counter

In 2021, the MHRA authorised the POM to P switch of two brands of desogestrel contraceptive pills, Hana (Perrigo)and Lovima (Maxwellia).

Lovima enjoyed a high-profile launch with significant media coverage and support from pharmacy retailers and sexual health charities. But brand manager Kim Wathall explains that the mid-pandemic launch wasn’t without its challenges, as pharmacies were “vastly overstretched” and more consumers switched over to private online doctor services. “As a result,” she says, “the OTC category has built more slowly than anticipated. However, it is continuing to build as more people learn about this new channel.”

The desogestrel switch and growth in online services have both changed the way women access their contraception. Prescription Cost Analysis data show a reduction in NHS prescriptions of desogestrel of eight per cent in 2021 compared with 2020, when 3.1 million prescriptions were written. 

Ms Wathall says Maxwellia recognises that not all women want, or can afford, to pay for their contraception, adding that the new pharmacy service represents “another great step forward for equality in women’s health”.

However, issues such as funding shortages and staff burn-out may affect roll-out, she adds: “Whilst the new pharmacy commissioned service presents a great opportunity for women, it does add increased administrative burden to already overstretched pharmacy teams.  

“The OTC contraception option provides the most time efficient service for both consumers and pharmacists, with simple, easy to follow supply information provided on the pack, and no requirement for updating records and systems.”

The first phase of the new pharmacy service is only for women who are already using oral contraception following a previous prescription from their GP, but Lovima and Hana allow women to start the progesterone only pill without a prior prescription. To find out more about Lovima and to complete the training, visit the dedicated Lovima healthcare portal.

A great POPortunity

“In pharmacy, we have an exciting and growing portfolio of support for women and people with uteruses seeking contraceptive options,” says Deborah Evans, a pharmacist with over 30 years’ experience. “Every customer is different and has unique life circumstances and so giving them choice is important, and this includes where they can access their contraception.”

She adds: “Being able to supply the progestogen-only pill (POP) means we can help individuals who don’t currently want to be pregnant, and for them to have autonomy over their sexual health. Being able to come into the pharmacy and almost instantly access the pill works especially well for those who may not be able to get or may struggle to attend a doctor’s appointment and still require access to contraception. 

“We also have the opportunity to provide an instant contraceptive solution to women who have come in for emergency contraception. It is a simple consultation not requiring blood pressure or weight checks and is suitable for many women of childbearing age.”

Views from the P3pharmacy panel

This is a popular category for us, especially for thrush. Most women don’t want to wait to get an appointment to see their GP for this as they want to treat it quickly. The whole Canesten range does well for us here. The single dose fluconazole treatment is probably the most popular, although the cream also sells well. The EHC pill is a popular request, although we don’t have a commissioned service in our area. ellaOne is the best seller. Viagra continues to be popular and it’s something customers may come to us for advice about.

We are the go-to place for thrush advice and women know to ask for fluconazole by name. We tend to sell more of the generic brands, although we do stock Canesten. We do an increasing number of Viagra consultations now and we are also the go-to place for EHC. We do well with Balance Activ. I think we could explore private STI testing, as this is not a commissioned service in our area. We stock Gina, but there has been little uptake so far. We get a lot of queries about HRT and menopause, and this is another area we could explore developing.

EHC and pregnancy tests do well for us. We find more men are coming in to ask for Viagra Connect and are less embarrassed talking about it. However, this does vary depending on the cultural heritage of the customer. For us, it’s important to have both male and female pharmacy staff for this reason. Durex is our best seller for condoms; Clearblue for pregnancy tests; ellaOne for EHC; KY Jelly for lubricants. Display needs to be discrete. We do display the Hana contraceptive pill, but Viagra Connect is kept in a drawer

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