• contraceptives
• postcoital
• pharmaceutical services
• sexual health

Sharon Cameron and our colleagues present a study investigating the provision of emergency contraception (EC) from pharmacies, using a mystery shopper methodology undertaken in Edinburgh, Dundee and London, UK.1 We report that most women were able to undertake their consultation in a private room and that half received advice about ongoing contraception. However, one in five women left the pharmacy without EC because of the unavailability of a pharmacist or lack of supplies of EC. This is unacceptable and the pharmacy profession, contractor bodies and commissioners have a role in raising the professional standards of all pharmacies to those of the best. Universal commissioning of free EC and ongoing contraception should be available through pharmacies regardless of a woman’s age.

The authors remark that although availability of EC from pharmacies improves access, women in the UK still require a consultation with a pharmacist and the privacy of a sensitive consultation for EC in the community pharmacy is not guaranteed. They conclude that opportunities to prevent unintended pregnancy are being missed and it is now time to make EC available as a general sales list medicine (GSL).1 We would highlight that access to EC from pharmacies brings with it a series of distinct advantages that may outweigh the potential advantages of deregulation. As a GSL medicine, EC would be able to be purchased by anyone from anywhere, for example, a corner shop or a petrol station with no advice given and no opportunity to identify needs for future contraception, possible symptoms of sexually transmitted infections (STIs), or potential issues with child and adult protection. In common with over 80% of countries worldwide, policy in the UK enables access to EC through a consultation with a pharmacist.2

Looking back, we can see that the provision of EC by community pharmacies has been a successful addition to the range of available sexual health services.3 Since the implementation in the UK 20 years ago, women have chosen pharmacies to access these medicines. There are a number of clear reasons why young women choose pharmacies to access EC: the local and convenient position of pharmacies within communities; longer opening hours, including evenings and weekends; the rapid access to EC through a pharmacy consultation, with no need to book an appointment to gain a prescription; and consequent administration sooner after unprotected sexual intercourse.4 Women from communities experiencing socioeconomic disadvantage are more likely to access EC from a pharmacy than from other services.4

The provision of EC from community pharmacies has been extensively evaluated and we are well aware of the strengths and weaknesses of current practice.5 Women may still commonly misunderstand how to access EC and how EC works. There are remaining moral concerns and stigma around provision of EC and some pharmacists may themselves create barriers to limit access, even though there is little evidence that provision of EC encourages risk behaviours.6 Women over the age of 20 years are more likely to use a pharmacy service than younger females, and those with greater health literacy are also more frequent users. However, there remains variation in pharmacy access, and longer opening hours and weekend opening are not universal. Reduced availability of pharmacy services on Sundays is a barrier to timely EC access. EC consultations in Wales peaked on Mondays and were associated with a longer duration between presenting and unprotected sexual intercourse (UPSI), which has implications for the efficacy of levonorgestrel EC.7

Women may not expect to be given further information on contraception or STIs by pharmacists and so may not be receptive to a comprehensive discussion about sexual health needs and advice.8 Variation in pharmacy practice is commonly seen, as is provision of advice not in line with guidance.9 Other sexual health providers are supportive of pharmacy provision and service development but highlight perceived barriers including pharmacists’ capacity and competency to provide a full contraception consultation, safeguarding concerns, and women having to pay for contraception.10 There are examples of outdated practice, including supervised consumption and lack of ability to access supplies for future use, that need to be addressed by the profession and commissioners.

Looking forward we can see that the clear advantages and benefits to women when service provision from community pharmacies is extended.11 There is also a growing recognition that specialist sexual health providers and general practitioners do not have the capacity and available workforce to meet the growing needs of the population requiring sexual health services and that their skills sets may in fact be better deployed managing complexity.12 Making a wider range of services available through pharmacies will benefit women seeking contraception.

Initiatives such as Umbrella in Birmingham, UK (https://umbrellahealth.co.uk/) have sought to integrate providers of sexual health services and to bring them within one overarching governance framework. This approach has aimed to mobilise the contribution of general practice and community pharmacy, as well as to emphasise work on safeguarding and health promotion. In this model, pharmacies can provide EC and STI screening, and may opt to initiate the combined oral contraceptive pill, progestogen-only pill and Depo-Provera, and follow-up hepatitis B vaccinations, as part of an integrated service.

Provision from pharmacies has enabled many more women to gain access to EC in a safe, convenient and cost-effective manner. The accessible contact with a health professional in the pharmacy also has the potential to enable women to access effective ongoing contraception. It is clearly a retrograde step to make EC a GSL medicine if this is the intention. Looking forward, it is clear that improving access to effective contraception for a greater proportion of women in our communities can be addressed through increasing the products and the commissioned services that can be accessed through pharmacies.