Collaborating with community pharmacists to deliver sexual health services

NHS sustainability and transformation partnerships and the Five Year Forward View aim to improve the integration of healthcare services in the UK. NICE recommends integration of community pharmacies in the wider health care system to improve patient choice and achieve better health outcomes for people in both primary care and the community.  We describe an approach to developing an integrated community-focused sexual health service that involves working closely with community pharmacists to deliver sexual health services in a city facing significant health, social and wellbeing challenges.

The project relates to NICE guidance relevant to sexual health, contraception, blood-borne virus testing (HIV, Hepatitis B and C) and the promotion of health in community pharmacies.

The aims of our project were to:

1. Improve awareness, accessibility and uptake of testing for sexually transmitted infections (STI) and blood-borne virus (BBV) testing (hepatitis B and C screening, hepatitis B vaccination and chlamydia screening) in the community via the development of sexual health services within community pharmacy networks. This is important, as it will help to reduce the number of people who are undiagnosed in the population and will enable earlier diagnosis, decreasing morbidity and mortality and reducing onward transmission of infection.
2. Improve awareness, accessibility and uptake of contraception within community pharmacist settings to improve delivery of contraceptive services for young people and to reduce unplanned pregnancies and teenage pregnancy rates.

We aimed to achieve these outcomes through the following processes:

1. Education of community pharmacists through our Umbrella Sexual Health Awareness Promotion and Education (SHAPE) training programme.
2. Establishing a Pharmacy working group within Umbrella Sexual Health - to develop the service delivery models and devise an implementation plan.
3. Stakeholder Engagement - to facilitate two-way communication between Umbrella and community pharmacists through regular engagement forums.
4. Development of IT systems for Data monitoring & Evaluation –We aimed to collaborate with community pharmacists to explore information technology systems that could be used for recording and monitoring of activity related to sexual health outcomes.
5. Health promotion and Signposting for patients, clinicians, and voluntary organisations to ensure best use of available resources, via our public-facing website and health promotion materials.

Prior to Umbrella, the traditional sexual health service model was mostly delivered in specialist clinical centres, resulting in fragmented care that focused heavily on treatment. In 2014, 800 service-users from a cross-section of backgrounds were surveyed; over a third cited community-based settings as a preferred place for sexual health care. Workshops with service users, agencies and third sector organisations from hard-to-reach communities were held, focusing on case-based studies of individuals with differing sexual health needs who presented in clinical and non-clinical settings. The workshops provided a user perspective and informed care pathways (using a “no wrong door” approach), community hub settings, delivery and community partners, branding and health promotion strategy. The Local Pharmaceutical Committee (LPC) were enthusiastic partners in service design and delivery. Umbrella transformed the model into a prevention-based, community-focused service.

Birmingham has a young population, with 25.4% of the population aged under 18 years, compared to the national average of 21.3%. Birmingham has a growing population, currently 1,128,000. It is culturally diverse. 40.3% of residents identify as an ethnic minority group compared to the national average of 13.6%. Birmingham is one of the 20% most deprived districts/unitary authorities in England (source: https://fingertips.phe.org.uk/profile/health-profiles/data#page/9/gid/1938132696/pat/6/par/E12000005/ati/102/are/E08000025).

The project will benefit:

1. Service users: Improved access to screening and testing within community settings will help to engage hard-to-reach populations and enable earlier diagnosis of STI and BBV, leading to improved health outcomes for patients, including reduced rates of pelvic inflammatory disease and opportunistic infection related to late diagnosis of HIV. Health promotion and provision of contraception in community settings will help to reduce teenage pregnancy rates. Collaboration with community pharmacists will improve patient care pathways.
2. Health and social care system: Reduced late diagnosis of STI and BBV will result in reduced morbidity and mortality, leading to decreased health and social care costs and improved economic productivity. Improved accessibility and uptake of contraception will reduce teenage and unplanned pregnancy rates.
3. Public: Health promotion and earlier diagnosis and treatment of infections will reduce onward transmission of STI and BBV.

We recognised barriers at the outset of this project. We needed to understand the commercial environment of the community pharmacists setting, the service specification needed to be designed, service tariffs and a procurement process were required for the tendering of services to pharmacists, a sexual health training package for pharmacists needed to be developed to ensure safe, high quality care for patients, an Electronic patient record (EPR) system needed to be identified and communication pathways needed to be developed with pharmacists.

We developed a Pharmacy working group, comprising clinicians, senior management (Business Manager and managers in health promotion, finance and education) and the LPC representative. This was key to overcoming traditional barriers between disciplines, and collaborating to effect innovative and sustainable improvement in patient care.

We aimed to engage a broad range of community pharmacists by offering a Tier 1 service (emergency hormonal contraception, condom distribution and dispensing STI kits for self-sampling that were ordered through the Umbrella online STI kit ordering system) and a more advanced Tier 2 service (Tier 1 services plus initiation of STI testing and provision of STI kits, Chlamydia treatment, Hepatitis B vaccination, initiation of regular contraception (pills and injections). We utilised an EPR (PharmOutcomes) for recording of data from consultations with patients and to enable evaluation of data and to generate activity-based payments, which community pharmacists were already using for other services that they delivered.

We maintained communication with pharmacists via email contact, held regular forums and regularly met with the Birmingham and Solihull LPC. We provided recognition for high-performing services and shared examples of good practice to promote shared learning amongst pharmacists.

We established a training program for Pharmacists with a face-face component in order to ensure quality assurance. Feedback from our pharmacists and our young persons’ mystery shopper exercise is also being utilized to identify further training needs. Our training team responded to feedback from pharmacists to streamline the training process, by designing an online component for the training package.

Our health promotion team produced materials for display in our pharmacies and in our clinics to promote sexual health awareness amongst service-users

This collaborative approach has been successful. 163 community pharmacies (100 Tier 1 and 63 Tier 2) now contract with us, delivering sexual health services on behalf of Umbrella. Our overall service activity in community pharmacies continues to increase. Monthly service activity figures in October 2018 confirm provision of: 2040 Emergency hormonal contraception (EHC), 123 chlamydia screens, 1022 condoms, 323 STI kits, 46 chlamydia treatments, 182 progesterone-only pill (POP), 33 contraceptive injections (Sayana Press) (Activity reports attached). Patients can now attend a community pharmacy local to where they live or work to access free condoms, emergency contraception, regular contraception, STI testing kits for infections (Chlamydia, Gonorrhoea, HIV, Syphilis, Hepatitis B if in an at-risk group), and Chlamydia treatment in Birmingham.

The traditional clinic-based service was costly and not meeting the needs of the population; this community-based model enables less costly additional service provision for previously unmet demand, allowing patients who find it difficult or prefer not to attend a clinic-based service to access services locally. Improved access to screening and testing within community settings enables earlier diagnosis of STI and BBV and has potential to reduce pressure on staff at overbooked Umbrella clinics. Our health promotion team develop a variety of promotion materials for display in Umbrella pharmacies and clinic-based services. We have recognised the importance of remaining up-to-date with the ongoing training requirements and have a robust online and face-face training package, overseen by our growing training team. 

Service development is ongoing and new barriers are now being recognised. There is wide variation in service activity levels across different pharmacies.  Reasons for this are being explored further. We aim to promote engagement of pharmacists across the board. A lack of guaranteed opening hours for pharmacists has made it difficult to confidently signpost patients away from clinic-based services to community pharmacist services. We are building relationships with individual pharmacies and are signposting patients from clinic to pharmacies that are able to guarantee specific hours. We aim to further improve signposting to pharmacy from our Umbrella website (www.umbrellahealth.co.uk) and are exploring the possibility of online booking with specific pharmacists who have this capability.

Stakeholder engagement is vital                                                                                               

Establish steering groups and forums with stakeholders                                                           

Clinicians and managers should work closely                                                                                                                                                                                                                            

Understand the working environment for community pharmacists

Invest in training and health promotion at the outset

Consider your IT systems carefully                                                                                                                             

The heterogeneity of IT systems across healthcare settings can create barriers to integrated care. We collaborated with pharmacists, by using an IT system that they were already familiar with.

Streamline processes where possible

Initial procurement process was an administrative burden; now simplified.

We needed to strike a balance between streamlining the training for our pharmacists and maintaining quality assurance:  An online module has been introduced.

Strategic procurement

Procure by need and consider which services are best delivered in the community

Review tariffs

Consider adding a minimum level of activity to the contract – may be wide variation in activity levels across pharmacists.

Build relationships and review communication pathways                                                        

Face-face contact - The better the engagement, the better the outcomes!                                                                                                                     

Regularly reflect and improve on existing practice.                                                                     

Celebrate success! Sharing success stories can support providers and is good for morale.