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THE
REFLECT
PLAN
ACT
E VA L U AT E
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
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
GOAL:
OBJECTIVES:
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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.
Premises
Manchester initiative
This CPD module is able to draw on the
experience of the pilot project developed by
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.
Source: DH Teenage Parents Next Steps: Guidance for Local Authorities and Primary Care Trusts 2007
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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.
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.
Practice point
What other factors should be considered?
Practice point
If the client is not suitable for a COC, what would
be your next course of action?
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
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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.
Practice point
How would you approach a refusal by a client for
this information to be supplied to their GP?
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
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.
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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
The need to consider the input and impact on other stakeholders when
setting up a sexual health service is considered
This module discusses the factors that need to be taken into account
in ensuring good clinical governance
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
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
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
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
Date:
How have I put this into practice? (Provide examples of how learning has been applied what did you do differently as a result?)
(Evaluate)
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.
a.
2.
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b.
b.
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b.
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c.
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correspondence
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into.
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