The decision by Boots chemists to provide emergency contraception in its stores has been criticised by doctors, writes JOANNE HUNT
CONTRACEPTION IS the old chestnut that never fails to raise hackles. It was no surprise then that Boots Ireland’s announcement that it was to provide an emergency contraception service, more widely known as “the morning-after pill” in 49 of its 50 stores raised a chorus.
What was striking, however, was the source of the objection.
The 1979 Family Planning Act making contraceptives legally available in Ireland for the first time, though only on prescription from a doctor, had yielded Charles J Haughey some interesting fan mail.
One group of women in Ballaghaderreen, Co Roscommon, feared that Ireland would “cease to be one of the last outposts of moral society”. Another objector sent Mr Haughey a blessed miraculous medal, saying, “No one is pleased, least of all God!”.
Thirty years ago, the dissenters grabbing the headlines were on the pro-life side. Last week, it was GPs.
The Irish College of General Practitioners (ICGP), the body comprising over 90 per cent of Irish GPs, came out strongly against the Boots move.
Boots is offering the service under a “patient group direction” (PGD) type of “group prescription” by which the company’s medical director has authorised its pharmacists to treat a group of people with a certain common condition with a specific treatment. In this case, it’s emergency contraception.
From Wednesday last, the company began its service of selling the medication following a one-to-one consultation with a trained pharmacist in a private consultation room. Demand, according to Boots, is strong.
The cost is €45, which in many instances is far cheaper than seeing a GP to get a prescription and then paying a pharmacist to fill it.
Speaking about the move, spokesman for the ICGP, Mel Bates, said, “We support the availability of the morning-after pill, we don’t have any concerns about its safety, we don’t have any concerns about the professionalism of our pharmacy colleagues.”
So what was exactly is their issue?
“From our point of view, I’d be afraid that the effect of all that publicity was that emergency contraception was the answer to their contraception needs and particularly that small vulnerable group who actually do rely on it like that.”
While welcoming the pill’s wider availability on one hand, the ICGP is also mindful that this could lead to its overuse or misuse.
“When you increase availability like that or you advertise it, you increase demand. If GPs advertised it, I’d have the same misgivings . . . there can be an overuse and the only one it benefits is manufacturers, GPs and pharmacists,” cautions Bates.
However, its increased availability is something Dr Caitriona Henchion, medical director of the Irish Family Planning Association (IFPA), says is welcome.
“This will just make access easier, there will be less of a delay in patients getting it – that’s the bottom line. Everybody is aware that the effect reduces as time elapses.”
A 2009 IFPA survey of women who attended its Cathal Brugha Street clinic for emergency contraception showed that 35 per cent of women only accessed such services between 24 and 48 hours after sex with a further 11 per cent delaying 48 hours or more. Henchion’s view is that “anything that means people can get it quicker and easier is a good thing”.
Dr Mary Condren, a GP in inner city Dublin who gives talks at girls’ secondary schools, agrees. “They ask, ‘Where can I get it’ and ‘How much does it cost’,” she says. “Studies show no increase in risk-taking behaviour, so on balance quick and easy access is the most important thing.”
Boots has dismissed the ICGP’s concerns with the company’s chief pharmacist, Mary Rose Burke, saying, “There’s no reason to think that pharmacists would be any more liberal in giving it out.
“In other countries, you don’t tend to see an increase in overall demand, you see a switch in where people avail of the service. They just have a choice of another place, but it doesn’t increase the number of people looking for the service.”
But if that predicted switch takes place, should GPs themselves be worried? And in a year when their renegotiated contracts with Government are likely to reflect the country’s poorer public purse, is it any wonder their representative body is defensive about any erosion of territory?
“It needn’t be portrayed as another blow against the cost of a GP visit,” says Mel Bates, adding that the overall impact on a GP’s bottom line will be “very small”.
While Boots doesn’t give a breakdown of its €45 fee, Burke says, “If somebody came into Boots with a prescription for the same medicines, they would pay roughly €17 to the pharmacy.”
That would put the Boots consultation fee at €28, which Burke says may include contraceptive and STD advice.
Bates, however, says that a GP visit “represents better value”, adding: “The pharmacist consultation is a single commodity, whereas very few people come to a GP with a single issue. If someone comes in to a GP with one thing and then they turn out to be depressed, most people don’t charge anything different from their standard consultation rate.”
But with the cost of a GP visit up to €60, Bates acknowledges that women going the GP route for emergency contraception “are not left a lot of change out of €70”.
He says, “I think that there are many GPs who haven’t fully considered the full cost of the morning-after pill after the mark-up that occurs after their prescription leaves the surgery.”
He says in the past, when the morning-after pill was “relatively inexpensive”, it was given as part of the consultation, something which GP out-ofhours services continue to do when pharmacies are closed. Bates says “that maybe something that some GPs would consider in the future”.
While Boots was the first mover, Irish Pharmaceutical Union president Darragh O’Loughlin says other pharmacies will soon follow. The expanding role of pharmacists is not something that’s likely to stop at contraception, he says.
“There are a lot of services that patients are currently receiving from GPs that they could receive just as easily from pharmacists,” says O’Loughlin.
“If pharmacies can take some of the less complex stuff out of the GP’s urgery, it would be more convenient for the patient and very cost effective,” he says.
With possible incoming health minister Dr James Reilly describes himself as a fan of “patients being dealt with at the lowest level of complexity”, this could be the beginning of a greater drift of services from over-stretched GPs to other community-based health professionals.
O’Loughlin, however, says it’s not about a land grab between GPs and pharmacists. “There’s no point in any of us getting sensitive or possessive. Patients are not prizes to be fought over . . . If it’s in the patient’s best interests and it’s cost effective, then it’s going to happen.”
The ICGP, however, is keen to stress its expertise in providing holistic and continuous care. Referring to the increased availability of medication such as emergency contraception, Bates says: “People need to look at the other angle . . . any professional who does this sort of thing needs to be worried whether their own human nature, greed or otherwise, is part of their motivation.”
A 2009 IFPA survey of women who attended its Cathal Brugha Street clinic for emergency contraception showed that 35 per cent of women only accessed such services between 24 and 48 hours after sex with a further 11 per cent delaying 48 hours or more
