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Dr. Evan Harris (Oxford, West and Abingdon): In this country, we spend much time and money in training pharmacists, only to lock them away in the back of chemists' shops. Does my hon. Friend agree that advice on emergency contraception is an example of how we could use the professionalism and expertise of pharmacists--properly remunerated, I should add--to take the load off national health service clinics and casualty departments, as she suggests?
Dr. Tonge: I thank my hon. Friend for that intervention, with which I whole-heartedly agree. Pharmacists often know much more than many general practitioners about drugs and their interactions. Indeed, I have often seen pharmacists save a difficult situation by correcting a prescription. So, yes, I would welcome greater use of pharmacists.
If the emergency contraceptive pill were made available over the counter, women would have to pay for it, which I believe would, in some cases, be a positive factor. Teenagers, particularly young teenagers, would be reluctant to pay for the pills again when they found out that they could get them free from a clinic, nurse or GP. That would have the added advantage of ensuring that very young people would, on the subsequent times that they needed this method, receive adequate counselling about their sexual behaviour, contraceptive needs and sexual health, which is what we all want. However, I appreciate that that may not be possible immediately.
A pilot scheme operating in Washington state allows for emergency contraception to be available on prescription. Under a protocol agreed by local doctors, local nurses and pharmacists may dispense the emergency contraceptive pill--they are, of course, trained to ask the right questions. The scheme has recently received the blessing of the only company in the United Kingdom that currently makes a packaged form of emergency contraception--Schering Pharmaceuticals--so there would be no difficulty in making emergency contraception available, especially in the light of the Crown review of the prescription, supply and administration of medicines.
The proposals that I have outlined would not make young women more vulnerable. Young women are most vulnerable when they have no one to turn to. They become scared and then they do nothing--they become yet another unwanted pregnancy or abortion statistic. If emergency contraception were made more widely available from nurses and pharmacists under a protocol, young women would have people to turn to at very short notice.
The Minister for Public Health (Ms Tessa Jowell):
I thank the hon. Member for Richmond Park (Dr. Tonge) for raising this important issue. I pay tribute to her, and to other hon. Members who have worked so hard--particularly in recent weeks--to focus public attentionon it. The question of ease of access to emergency contraception is an essential part of broader family planning provision.
The hon. Lady made very clear the case for accessible emergency contraception. Emergency contraception is precisely that: contraception to be used in an emergency, possibly when the regular form of contraception fails. As the hon. Lady rightly said, without it many women may live in fear of an unwanted pregnancy, and may be forced into seeking an abortion. Abortion is, of course, a last resort, but too many women in Britain today resort to it because contraception has failed. In 1997, 170,000 abortions were carried out, the majority for women in their 20s.
Let us look briefly at the facts about emergency contraception. It is provided free as part of national health service comprehensive family planning services. Although we are talking about a pill on this occasion, it is important to remember--as the hon. Lady pointed out--that emergency contraception is available in two forms, the copper intra-uterine device and hormonal emergency contraception.
Hormonal emergency contraception, on which I want to concentrate, was first licensed in the United Kingdom in 1984. It is effective for up to 72 hours after unprotected sex--a fact which I still do not think is lodged sufficiently in the minds of many women, especially young women. It prevents a fertilised egg from being implanted in the uterus, or, alternatively, suppresses ovulation. As the hon. Lady said, it is very effective: more than 95 per cent. of women who take emergency contraceptive pills do not become pregnant. However, it is intended to be used only occasionally, and is not a form of long-term birth control. As the hon. Lady said--I want to underline this--neither is it a form of abortion.
From the data that we have on prescription items, we know that more emergency contraception is being used. As I said in a parliamentary written answer to the hon. Lady, the number of prescription items increased from just under 400,000 in 1992-93 to well over 700,000 in 1996-97.
Emergency contraception is safe and effective, with few contra-indications. Safety and correct use will remain paramount, whatever changes are made in the future to
ease accessibility. A study published today suggests that making emergency contraception more easily obtainable does no harm, that women are not more likely to use emergency contraception repeatedly and that the rate of unwanted pregnancies may be reduced.
The hon. Lady is interested in exploring further whether hormonal emergency contraception might be made more widely available through different routes. I think that we can do much more both to increase information for women and to improve access through existing services.
The current position is that emergency contraception is classified as a prescription-only medicine under both European Community and United Kingdom law. Medicines are so classified if they are likely to present a danger, either directly or indirectly, even when used correctly, if taken without medical supervision; or if they are frequently used incorrectly and, as a result, are likely to present a direct or indirect danger to human health.
Dr. Tonge:
Does not the Minister accept, having listened to the experts and to what I said tonight, that the emergency contraceptive pill does not fit into either of those categories?
Ms Jowell:
Those are the terms on which the emergency contraceptive pill is currently licensed. That judgment is made by the licensing authority. There is a well-established process for changing the legal classification from prescription-only to pharmacy availability.
The first stage is that the holder of the marketing authorisation, being satisfied of safety in use, proposes the change. My understanding is that only one company is licensed to produce the emergency contraceptive to which the hon. Lady referred. The proposal can come from other sources, and has on occasion come from professional bodies.
It is important to stress that third parties, whoever they may be, must still have detailed information on safety in use, and the manufacturer must be involved in producing patient information for medicine use in the absence of medical supervision.
The second hurdle is the assessment of the safety of a change in classification, which involves the assessment of available scientific and epidemiological evidence by the Medicines Control Agency; careful consideration of the medicine's risks and benefits; rigorous evaluation of the evidence on safety in use; and an evaluation of the direct danger of the medicine based on an assessment of the seriousness, severity or frequency of adverse reactions.
There is also an evaluation of any indirect danger to health; for example, wider public health issues, such as a possible increase in sexually transmitted diseases if increased use of the emergency pill leads to decreased reliance on barrier methods, must be considered.
The third stage is for the Committee on Safety of Medicines to consider every application for deregulation from prescription-only status to pharmacy availability. The committee examines again the evidence of safety in use in relation to criteria for prescription-only status and advises on the product's risks and benefits in the context of its proposed over-the-counter availability.
The penultimate stage is public consultation. If the committee is satisfied that the risks and benefits are acceptable, on the basis of the available evidence, a period
of public consultation follows. Consultation makes possible a wider debate on the social, ethical and moral aspects, as well as the scientific and broader public health issues. The responses are then considered by the Medicines Commission. Only after those four stages have been completed does the Medicines Commission advise Ministers on the proposal to amend the prescription-only medicines order. Ministers then make a decision. Emergency contraception is no exception to that process.
Another route, to which the hon. Lady alluded, is the supply and administration of medicines under group protocols. As she knows, the Crown review into the prescribing, supply and administration of medicines has been considering related issues. The full review is drawing towards a conclusion, and Ministers expect its second report in the summer. The first report, setting out recommendations for the supply and administration of medicines under group protocols, was published towards the end of April, and recommended that the majority of patients should continue to receive medicines on an individual basis, but that group protocols should be used in certain limited situations.
The provision of contraception as part of a comprehensive family planning service could be one such area. Highly qualified nurses are working in family planning, and some of them are currently working effectively under group protocols. I believe that the first report of the Crown review forms a solid basis for setting standards to develop good practice in that area of care. We wish to consider the implications carefully before consulting further on detailed proposals, and we hope to undertake consultation in the next few weeks.
The hon. Lady referred to the scheme being conducted in Washington state in the north-west of the United States of America. Pharmacists are participating in a pilot study in which a collaborative agreement between pharmacists and a prescribing clinician enables the pharmacists to provide the emergency contraceptive pill directly to women according to an agreed protocol. That is a new project in its early days of piloting, and I understand that it will be subject to proper evaluation. We certainly want to consider carefully the implications for the United Kingdom of that type of experiment.
I want to deal with some of the broader aspects. What I have said will make it clear to the hon. Lady that the immediate change is not in prospect. It is essential, however, to consider how we can make emergency contraception more accessible to women who need it. As the hon. Lady said, for the emergency contraceptive pill to be effective, it must be readily accessible within the 72-hour window of opportunity. It can be prescribed by any general practitioner who provides contraceptive services, and it is available at any family planning clinic, most genito-urinary medicine or sexual health clinics and some accident and emergency departments. Young people can also go to young person's clinics or Brook advisory centres. It is not acceptable for women to have difficulty making appointments with their GPs, to find family planning clinics closed or to be turned away from accident and emergency departments. Health authorities should ensure that that does not happen.
No matter how accessible the contraception is, the other side of the coin is information. People must be aware of what emergency contraception offers. Women need timely information about the accessibility of emergency contraception, and about how it works and when it should
be taken. Raising awareness has been a key Government priority. The Department of Health recently funded an awareness-raising campaign by the Health Education Authority, which stressed that the emergency contraceptive pill can be taken up to 72 hours after unprotected sex, and that the other form of emergency contraception--the copper intra-uterine device--can be inserted after up to five days. I am heartened by much of the media coverage that has sought to dispel the myth of the morning-after pill. The hon. Lady referred to what she considered to be irresponsible reporting, but we need to recognise that the media can be important allies for us, particularly in getting the message across to vulnerable young women.
Just lately, some responsible reports referred to the 72-hour time interval, which remains insufficiently understood. More broadly, it is important to get across to as many women as possible further information about exactly how emergency contraception works.
The contraceptive education service run by the Family Planning Association, with Department of Health funding, has published a detailed leaflet for women and their partners on both forms of emergency contraception. As part of contraceptive awareness week, it has launched an information pack on emergency contraception for health promotion units. The service provides answers to questions from women and their partners across a wide range of contraceptive issues, including emergency contraception, and the CES helpline provides information on the location of family planning clinics.
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