Background

I admit it. I’ve personally often used pharmacies as good sources of information, support and product. So it’s with more than professional interest that I’m undertaking my latest Journal commission: to explore the role of pharmacists in the field of sexual and reproductive health care (SRH).

This exploration has been triggered by the fact that said role is expanding. It was in the early 1980s that pharmacies become more involved in wider health care; the 2001 introduction of emergency contraception as pharmacy prescribable consolidated this involvement. The 2005 White Paper ‘Choosing Health Through Pharmacy’ widened the pharmacy brief of information delivery, including information on SRH. And recently, with the rise in home testing for pregnancy, fertility and some sexually transmitted infections (STIs), the high-street pharmacy has become an increasing conduit for advice and guidance of the kind that we Journal readers often deliver in our surgeries and clinics.

The trajectory of pharmacy involvement in the field is therefore undeniably onwards. But is it positively upwards? I’m especially interested in what those on the frontline think. Consumers – are they happy with the trend? Pharmacists themselves – do they see problems or opportunities on the horizon? Specialist professionals – are they wary or welcoming to the incomers? To find out, I approached representatives of all these constituencies, not only consumers but also pharmacy representatives, plus a variety of health professionals, who reported not only their own professional opinions but also the anecdotal perspectives of their consumer clients.

Accessibility

To begin with, the good bits. Almost everyone waxed lyrical about the advantages of pharmacy provision. The most-mentioned advantages were accessibility and convenience. No need to register. No need to make an appointment. No waiting around: if a pharmacist isn’t free, simply do a little more retail therapy and pop back. No closed doors: while the clinic or surgery may offer only 2 hours night and morning Monday to Friday, most pharmacies are open 8-til-late, some even all night.

As well as literal accessibility, the next most-mentioned advantage was what one might call ‘emotional accessibility’. As one respondent put it, “everyone knows what a pharmacist is”, with the implication that ‘everyone’ is comfortable dealing with a pharmacist in a way they aren’t when dealing with a general practitioner (GP).

Further, the conclusion was drawn by many respondents that because everyone visits a pharmacy not only for medical supplies but for feel-good products such as cosmetics, they may feel comfortable and relaxed when there. Anxiety, it was suggested, is lower because “whatever you ask about … feels much less a big deal … than when you go to the surgery”. The public may therefore be not only more able but also more willing to visit a pharmacy for slightly embarrassing issues such as suspected STIs or fertility testing. Pharmacies are not only emotionally accessible, but also emotionally reassuring.

Taking the strain

Equally, as compared to surgery or clinic visits, consumers seem to feel less guilty when consulting a pharmacist. “I don’t feel I’m wasting my doctor’s time … I’m not bothering anyone”, which is good news despite the back-handed compliment of implying that it’s better to waste a pharmacist’s time than to waste anyone else’s!

There is also a sense that with a pharmacist, one may feel less embarrassed and compromised. “I might expect a lecture from my GP … much better than going into the clap clinic … mentioning sex to your doctor could impact on your care … a pharmacist doesn’t know you [and this is good].” This last point, about anonymity, was seen as a huge advantage, although see my later comments on how lack of privacy in pharmacies undermines this benefit.

As to trust and credibility, a majority of the consumers, all the specialist health professionals and (unsurprisingly) all the pharmacists I canvassed had an underlying belief in pharmacy professionalism, training and expertise. And though one might expect the health professional cohort to be chary of ‘competition’, they simply weren’t. In fact, quite the opposite. The addition of pharmacies to the sexual/reproductive health roster was seen as giving the public more means of entry to services at a time when the National Health Service (NHS) is under pressure. As one expert commented wryly: “There’s more than enough work for everyone!”, and if pharmacies can take some of that strain, then they’ll surely earn the undying gratitude of the frontline troops.

In short, almost everyone I approached echoed the feelings of the patient who commented: “The pharmacist is much more accessible – and just as useful [as my GP]”.

Mind the gap

So far, so good. But all was not as it seemed. For while the professionals I consulted – and their patients whose opinions the professionals reported – all seemed to have direct experience of the issues, when I looked more closely at the 14 consumers I’d approached, there was a slight problem. For while consumer comments were almost entirely favourable, actual experience was limited. Of the 14 consumers in my straw poll, only four had ever consulted a pharmacist about a sexual or reproductive health matter.

A key issue here was the one that forms the headline of this article: “I … didn’t know that I could”. Of the 10 consumers who hadn’t used pharmacy SRH services, three didn’t realise those services existed and another five realised in theory but had never used them; their positivity came from general experience of pharmacy services. Once aware of what was possible, they were motivated to take up the offer with regard to SRH issues. (The two consumers who refused to use pharmacy services for intimate issues had had bad experiences of general pharmacy provision.)

Plus, everyone I canvassed – including the pharmacists themselves – had some concerns, even if these were theoretical rather than based on evidence. The most mentioned was privacy/confidentiality. As I hinted earlier, consumers may like the anonymity of speaking to a pharmacist but the lack of privacy can mean that anonymity counts for little. While many pharmacies have provision for separate and private consultation, not all do and for sexual health issues in particular one needs privacy to talk freely, to focus without distraction, and to express concerns without identification. Otherwise, as the Brook representative said: “It takes a skilful pharmacist and a brave … person to [talk about sexual health] in the context of filling prescriptions and selling cough remedies”.

Consumer wariness

Among consumers, there was also some wariness of the pharmacist’s role. Some clearly felt that they didn’t want to talk to a non-specialist about intimate matters. “I never thought of [them] as being experts … what [relevant] training do they have … I’m unsure who’s the pharmacist and who’s the retail assistant … I respect my GP more…”.

There is also some suspicion of pharmacy motivations. “I’m wary they may try to sell me something I don’t need … what happens if they are giving out health advice – is that going to raise their wages and so put up the price of what they sell …”.

To stave off the flurry of horrified gasps from pharmacists reading this, I would add that such comments are clearly due to ignorance of what pharmacies offer, what qualifications pharmacists have, and what the ‘deal’ is between pharmacist and retail outlet. But I do feel it’s useful to pass on the fact that such ignorance exists, and that it’s affecting take-up of pharmacist services and advice.

Health professional wariness

Specialist professionals are a little wary too. So, for example, they worry whether the fact that some pharmacists can offer only a limited range of options will impact on effectiveness; as independent contractors, indeed, pharmacies only provide comprehensive NHS services if commissioned by the local authority. Professionals worry too whether the restricted (and sometimes costly) range of medicines pharmacists sell ‘over the counter’ without prescription limits the solutions offered. They wonder whether – as pharmacists diagnose and prescribe on the patients’ say-so and have no access to medical records – the appropriateness of pharmacy advice might be compromised.

But professional wariness was typically bounded by huge confidence in pharmacies and a belief that pharmacy services were useful. Health professionals’ concerns were much less based on worry about the quality of the service and much more on personal knowledge of how complex and demanding SRH work can be, and whether pharmacists have enough resources and support to enable them to cope.

So professionals worry that – given the cutbacks across the medical profession – the training that pharmacists receive on sexual issues is likely to be too little and irregular. They worry that – considering that many specialist professionals themselves find it embarrassing to tackle intimate issues in the consulting room – pharmacists, with less time, less privacy and fewer resources, will find the task even more challenging. They also worry that pharmacists may be resourced (or allowed) only to provide medical solutions rather than giving broader advice based on knowledge of SRH.

Two respondents also highlighted the danger of pharmacists taking a wholly normative stance, such as assuming that all sex involves penetration, that a woman asking for pregnancy advice is necessarily heterosexual, or that the elderly, the single or the disabled do not have or want an active sex life. If dedicated SRH professionals fall into these traps, how will pharmacists steer clear of them?

Finally, but perhaps most disturbingly, some of the specialist professionals I approached admitted to being confused and uncertain about the whole issue of pharmacy involvement in the intimate arena. In the words of one respondent: “Has service provision in pharmacies been scoped, mapped, researched? What is really going on out there?”.

What's to be done?

So far, so worrying. Do the above concerns mean that pharmacies should stop offering SRH guidance? I am glad to report that the answer is a resounding ‘No’.

Despite doubts, the overwhelming feeling from most of my respondents (even the ones who hitherto had no direct experience or even knowledge of the service) was that what pharmacies could offer is hugely useful, and that where there is shortfall, that is largely down to lack of resources.

So what needs to be done? The messages that come through are clear and direct and often from pharmacy representatives who are highly motivated to continue to improve and enhance their service.

It would be wonderful if someone somewhere could do a full review of what was happening in pharmacies or, if such a review exists, could please copy in SRH professionals who haven’t yet come across it.

It would be wonderful if the already existing good training available to pharmacists could be comprehensively expanded. It would be wonderful if every pharmacist was able to talk comfortably to customers about intimate issues, to give pertinent advice and up-to-date guidance, to do so on a broad range of problems, with a full awareness of different practices and possibilities, and could know precisely when and how to refer customers on for specialist advice.

It would be wonderful if all pharmacies were equipped with private space so that customers are able to seek help freely and confidentially. It would be wonderful if all pharmacies clearly signposted the professional qualifications and expertise of their staff so that customers are able to feel confident as they seek that help.

And it would be especially wonderful if everyone knew what pharmacists were capable of, what they were offering, what they were keen to provide – if not only pharmacies themselves but also GP surgeries, family planning clinics, and the media could publicise and promote this knowledge. [NB. In this regard, Dr Anatole Menon-Johansson, Clinical Director for Brook, has independently set up a website (http://www.sxt.org.uk) to support consumers and providers to accurately match capacity with demand. The aim is to move towards a single digital platform to provide high-quality information and intelligent signposting so that consumers can find relevant services when needed.]

Offering a welcome

I have a final “It would be wonderful” – this time not aimed at the pharmacy profession but at Journal readers. It would be wonderful if we could add our support to help our pharmacy colleagues do all of the above. The role of the pharmacist is inevitably expanding and will continue to do so. Given the public need for as much guidance as possible, and given the need for as many health professionals as to give that guidance, it would be wonderful if we could support that expansion.

Whatever doubts we may have – about what is happening, about what is available, about the quality is of what is available – let’s turn those doubts into energy to resolve the issues. Let’s share the knowledge, the expertise, the experience and the insights that we’ve gained. Let’s even swap notes to support our patients even better. In short, let’s welcome the pharmacists in.

So that while not all consumers will choose to talk to their pharmacist, those who want to will never comment: “I honestly didn’t know that I could”.