Access to contraception in primary care leaves much to be desired — community pharmacy should prescribe, as well as supply, pills and patches

If you were to ask a healthcare professional: “What’s the most important biomedical advance of modern history?”, most would likely say antibiotics — which undoubtedly transformed the way we treat infectious diseases.

But we must not downplay the importance of another medical revolution: contraception. From the first mass-produced rubber condoms in the 1860s to the contraceptive pill in the 1960s, these products — along with legal access to safe abortions — have given women greater control over their sexual and reproductive behaviours.

Preventing unwanted pregnancies radically enhances women’s ability to meet their educational, employment and life ambitions, and contraception has been a major catalyst for gender equality in our society

With effective contraception, women can decide when, or if, they want to become pregnant. Preventing unwanted pregnancies radically enhances women’s ability to meet their educational, employment and life ambitions, and contraception has been a major catalyst for gender equality in our society.

The Faculty of Sexual and Reproductive Healthcare (FSRH) at the Royal College of Obstetricians and Gynaecologists knows this well, and when the COVID-19 pandemic took hold in the UK, it was concerned that the lockdown would cause women harm. So, in March 2020, it quickly responded with guidance for maintaining essential sexual health services — making it clear that “it is imperative that women of all ages can access effective contraception.” In the height of the lockdown, there was concern that women would struggle to meet their contraceptive needs^[1],[2]
.

And later, in May 2020 — when the FSRH understood that physical distancing would be an ongoing requirement — it backed consulting and prescribing by GPs, both over the phone and by video^[3]
. It also argued for easier access to products such as progestogen-only pills (POPs), and advocated greater use of long-acting reversible contraceptives (LARCs), such as intrauterine devices (IUDs), intrauterine systems (IUSs), implants or injections^[3]
.

Before the pandemic, however, cuts to public health funding and pressures on general practice were already causing problems for women’s access to LARCs, so how will we improve access through primary care in our new circumstances?

There’s another way of providing contraception. The pressure should be eased on GPs, to allow them more time to provide LARCs. Pharmacy can take some weight off to help them do this — it’s time for community pharmacists to prescribe contraceptive pills, patches and vaginal rings, as well as supply them.

We need to start by learning from our previous successes in reproductive health policy

Dedicated contraception policy

We need to start by learning from our previous successes in reproductive health policy. In 2018, conception rates in England and Wales among women under 20 years were half those recorded at the start of the 1990s, while rates among those aged 40 years and over have more than doubled in the same period^[4]
. Similar trends have taken place in Scotland and Northern Ireland.

In the 1990s, Britain had the highest rates of teenage conception in Europe. The decline in births to women aged under 20 years followed a funded strategy that was implemented in 2000, to prevent teenage pregnancy through improved education about sexual relationships and contraceptive provision, along with positive support for teenage parents to engage in education, training and employment^[5]
. This successful government initiative shows the value of informed health and social policy making.

Looking at current trends in contraception

We also need to consider women’s relationships with contraception today. Scarce and outdated data make this difficult, but, based on various sources, an estimated quarter of UK women aged 15–44 years (numbering around 12 million) are not using any form of contraception, for reasons ranging from not having heterosexual sexual relations to their actively seeking pregnancy.

An estimate of around 30% of these women are using either combined oral contraceptive (COC) or POPs, while around 25% are using barrier methods.

Up to 2% of UK women may be reliant on the repeat use of emergency hormonal contraception (EHC). Pharmacists should be aware that EHC suppresses ovulation rather than preventing implantation or acting as an abortifacient, and advise all women seeking EHC about the superior efficacy and other benefits of copper IUDs.

However, those currently using LARCs (including injectables, implants, IUSs or IUDs) represent little more than 10% of the English population ‘at risk’ of pregnancy, despite LARCs being more effective in typical day-to-day use than most other forms of contraception, because they do not require women to actively seek to assure their optimal use^[6]
.

Why we should recommend long-acting reversible forms of contraception

Access to publicly funded contraception across the UK remains good by international standards. However, LARC uptake in Britain is significantly lower than in countries such as Sweden^[7]
. And in late 2018, half of English councils were revealed to have cut, or planned to cut, sexual health services — particularly affecting the provision of LARCs^[8]
.

In 2020, few women obtain their contraception through specialist sexual health clinics. The Health and Social Care Act 2012 shifted public health services to local government and, since then, the resources available for their provision have fallen by around 20% in England. As a result, the proportion of women of reproductive age accessing contraception through specialist clinics is now well under 10%^[9]
.

Community pharmacy could safely supply and monitor progestogen-only and combined hormonal contraceptives

The great majority of women prefer to use GP surgeries and community pharmacies to access their contraception, yet few GPs offer a full range of options — including IUSs or IUDs — owing to a lack of funding, training and time^[10]
. With LARCs being the most effective type of contraception, this culture in general practice should change^[11]
.

While GPs improve their LARC offering, community pharmacy could safely supply and monitor progestogen-only and combined hormonal contraceptives (CHCs; including pills, patches and vaginal rings).

And there’s public appetite for this way of providing contraception. In my research with the London School of Economics in 2016, 44% of 800 women aged 18–50 years in England said they think current NHS arrangements for accessing contraceptives could be more convenient, and evidence points to pharmacist-led supply^[12]
.

Initiating contraception in the community pharmacy

Women can also access contraception through private internet supply, but the personal support NHS pharmacies can offer may be preferred by many

Public Health England has plans to increase LARC uptake in general practice. Pharmacy can complement these improvements to accessing contraception through primary care^[13]
. Given the long association between community pharmacy and access to contraception, the case for allowing pharmacy professionals (when women choose to consult them) to initiate and safely manage use of both POPs and CHCs has become increasingly powerful.

Women can also access contraception through private internet supply, but the personal support NHS pharmacies can offer may be preferred by many. In England, one of the better-known local examples of innovative contraception supply is in Southwark and Lambeth, where a pilot scheme has shown that pharmacists initiating POP use with a patient group direction (PGD) is not only feasible, but valuble: women who used the service were largely very satisfied and would recommend it to others^[14]
. 

Around the world, many countries that do not have the advantages provided by PGDs or the UK’s P medicine category already permit COC and POP supply on an over-the-counter (OTC) basis. During the development of World Health Organization guidelines, a review — based on evidence from the United States and Mexico — found that women receiving oral contraceptives on an OTC basis have better continuation rates than those obtaining them through a traditional medical route^[15]
. Its authors also found some indications that OTC pill users have lower rates of experienced side effects; however, OTC users were slightly more likely to have contraindications to their use of the contraceptives.

This latter observation is concerning, despite evidence that women can successfully self-screen for contraception-linked risks. But issues relating to safety should not act as a barrier to change in the pharmacy setting^[16]
,[17]
.

Women want more from the NHS’s contraception offering and extending the initiation and management of POPs — and other hormonal methods — to pharmacy could be the beginning of a solution. Pharmacists could start by offering POPs and progress to provide CHCs. Such innovations should be accompanied by renewed efforts to optimise access to all types of emergency contraception and abortion, when needed. Additionally, subject to funding arrangements and training, pharmacy could make wider contributions to improving sexual and reproductive health-related advice.

Pharmacy can only make these contributions when it moves away from dispensing-oriented attitudes and interactions

New kind of caring pharmacy

However, pharmacy can only make these contributions when it moves away from dispensing-oriented attitudes and interactions, towards more open, non-judgemental, user-focused consultation styles.

The wider system must let go of traditional routes to contraception — the pandemic has exposed the dangers of ‘we’ve always done it this way’ — and we must put our trust in pharmacists to help women gain access to the widest and most convenient range of choices.