Eleanor Brown (left) and Dr Richard Ma discuss the delivery of contraceptive services and how improving access to intrauterine LARC methods could reduce costs

  • The UK has the highest rate of unplanned pregnancy in western Europe
  • Uptake of more effective methods of contraception could help to address this problem
  • LARC contraceptive methods are known to be much more effective at reducing unplanned pregnancies than shorter-acting forms of contraception
  • Cost savings could be made from increased use of LARC, as there would be fewer unplanned pregnancies
  • Uptake of LARC increased during 2012/2013 but use of intrauterine contraception remained low compared with other ‘user dependant’ methods
  • The yearly cost of IUDs/the IUS is significantly less than for other long-acting methods, and savings are delivered after 1 year of use
  • NICE recommends the IUS for the management of heavy menstrual bleeding, as well as for contraception3
  • Women should be offered the full range of contraceptive choices (including LARC) through open-access services
  • Local authorities now commission comprehensive sexual health services, including provision of IUDs/the IUS for contraception and the management of heavy menstrual bleeding9 and emergency contraception, but there are no requirements for the number, location or staffing of these services
  • All providers of IUD/IUS services need to be trained to a suitable standard and be accredited by the relevant professional body.

Thirty percent of all pregnancies in the UK are unplanned. Furthermore, the UK has the highest rate of teenage pregnancy in western Europe.1 This situation could be addressed simply by offering more effective methods of contraception to women who might benefit.

Long-acting reversible contraception (LARC) methods are recognised as being much more effective at reducing unplanned pregnancies than shorter-acting forms of contraception, as they do not rely on patient concordance. They are defined as contraception that can be administered less than once per month or per cycle,2 and so include the:

  • copper intrauterine devices (IUDs)
  • the intrauterine system (IUS)
  • progestogen-only injections
  • progestogen-only subdermal implant
  • vaginal ring.

For further details about the methods listed above, see Box 1.

When NICE published CG30 on Long-acting reversible contraception in 2005, the vaginal ring was not licensed and so was excluded from the guideline.2 It should additionally be noted that, in CG44 on Heavy menstrual bleeding, NICE also recommends the use of the IUS for non-contraceptive purposes, that is, in the management of heavy menstrual bleeding (HMB).3 The IUS can be prescribed for HMB in any setting, including in community contraceptive clinics.

Box 1: Summary of available long-acting reversible methods of contraception*

  • Intrauterine devices:
    • copper-based, hormone-free
    • licensed for 10 years of use
    • reversible
    • very few contraindications
    • may cause painful and heavy periods
  • Intrauterine system:
    • slow-releasing progestogen hormone on a T-shaped frame
    • licensed for 5 years of use
    • reversible
    • few contraindications
    • may be useful for women with heavy menstrual periods
    • some hormonal side-effects are possible
  • Progestogen-only sub-dermal implant:
    • slow-releasing progestogen hormone released from a flexible rod inserted just underneath the skin in the arm
    • licensed for 3 years of use
    • hormonal side-effects are possible and there is a risk of irregular bleeding
  • Depot medroxyprogesterone acetate:
    • progestogen injection every 12 weeks
    • reversible contraception but may delay return of normal menstrual cycles
    • may affect periods
    • hormonal side-effects possible
  • Vaginal ring:
    • combined oestrogen and progestogen hormones
    • one ring a month with a ring-free week
    • regular artificial periods
    • risk of hormonal side-effects.
  • * All can be used in nulliparous and young women under 25 years

Current trends in contraceptive choices

Uptake of LARC has increased recently: according to the most recent data on contraceptive services, 30% of women who attended a contraceptive clinic chose a LARC method. Overall use of intrauterine contraception (including IUDs and the IUS), however, remained low at 9%, whereas ‘user-dependent’ methods (e.g. condoms and the oral contraceptive pill [OCP]) remained high at 68%.4

Increased use of LARCs may help local areas to deliver one of the targets in the public health outcomes framework for health improvement—specifically, to reduce conceptions in women under 18 years.5 It is expected that savings could be made if more women of childbearing age used LARC methods, as this would result in fewer unplanned pregnancies overall.6

This article discusses the implications for commissioners and providers of local contraception services of three key documents:

  • NICE CG30 on Long-acting reversible contraception2
  • NICE Services for the provision of IUDs and the IUS for contraception and the management of heavy menstrual bleeding commissioning guide7
  • Faculty of Sexual and Reproductive Healthcare Service standards for sexual and reproductive healthcare.8

Local authorities have been the new commissioners of specific sexual health services (including contraception) since April 2013, and so the implications of the Department of Health’s Commissioning sexual health services and interventions: best practice for local authorities are also discussed. 9

Cost of IUDs and the IUS

While commissioners may be deterred by the upfront costs of IUDs and the IUS, cost-effectiveness data have shown that:6

  • the yearly cost of IUDs and the IUS is significantly less than for other types of contraception (including other long-acting methods, such as the
    sub-dermal contraceptive implant)
  • savings are delivered after 1 year of use.

The NICE cost impact report on LARC estimated that for a primary care trust area (as it would have been then) with approximately 40,000 women aged 15–49 years, a 7.7% shift from using OCPs to IUDs/the IUS would result in an annual saving of approximately £300,000.6

Improving access to services

Access to contraception has been improved recently through the integration of sexual and reproductive health services, particularly in community contraception clinics. It is important that services in a local area are ‘open access’, meaning that all women across all age groups are able to self-refer to access all methods of contraception, including IUDs or the IUS, irrespective of their age or area of residence.8 One of the cornerstones of encouraging a greater shift towards the use of IUDs or the IUS and other LARC methods is increasing the availability of such open-access services, which should offer a range of contraceptive choices in order that women understand the methods that are open to them and where to obtain them.

Commissioning a service for IUDs and the IUS

Setting the local strategy

The IUDs/IUS are currently offered through a range of providers:

  • hospital-based specialists
  • community contraception clinics
  • general practice.

Most GPs are able to provide progestogen-only injections and vaginal rings as part of basic contraceptive services but other LARC methods require additional training and accreditation to ensure that they are delivered safely and competently (see ‘Ensuring access, quality, and safety’, below).

In general practice, service provision is laid out in the General Medical Services contract, which includes giving contraception advice on the full range of methods.10,11 Additional services— for example, insertion of IUDs and the IUS—should be contracted by local authorities, using the national enhanced service specification as a template and example.12 There is no requirement for the local authority to commission training for GPs; the funding for GP training is usually down to individual GPs or surgeries but local authorities must ensure that proper clinical governance mechanisms are in place. Local authorities are also responsible for comprehensive sexual health services, which will include provision of
IUDs and the IUS for contraception.

NICE estimates that, as a standard benchmark, 2% of contraceptive consultations in women aged from 15–54 years (or 2000 per 100,000 population) should relate to the use of IUDs or the IUS. NICE recommends this benchmark as a tool to start determining the level of service provision that may be needed locally, and to calculate the indicative benchmark using local data.6 The NICE costing template can also be used by commissioners to calculate the approximate levels of investment needed and expected future savings.13

Although local authorities are now required to commission comprehensive sexual health services, there are no requirements on the number of services that should be provided in any area, where they should be located, or how they should be staffed, although all of these factors will impact on the quality of the service and outcomes. The Advisory Group on Contraception notes that there are several innovative models that could be considered, including:7

  • GPs ‘with a special interest’
  • enhanced GP service provision
  • nurse-led care models.

The service model used should be determined locally, by using data on the needs of the local population.7
For instance, in areas with high rates of teenage pregnancy and/or abortion, increasing LARC provision would be a key component of a strategy to address these problems. In areas where IUD/IUS service provision is below the 2% benchmark, healthcare professionals may need better guidance and training so that they can help women to make an informed choice. Investing in developing professional competency to offer intrauterine techniques (IUT)takes time and planning on the part of commissioners.14

Ensuring access, quality, and safety

Low uptake of IUDs/the IUS is often indicative of barriers to accessing services, particularly a lack of trained practitioners. Commissioners may want to start by assessing capacity to meet demand at the outset. All providers of IUD/IUS services need to be trained to a suitable standard and be accredited by the relevant professional body, for example with a Letter of Competence in Intrauterine Techniques (LoC IUT) from the Faculty of Sexual & Reproductive Healthcare (FSRH) or the Royal College of Nursing (for doctors and nurses, respectively).15

It is recommended that all practitioners conduct a minimum of 12 intrauterine contraceptive insertions over 12 months, of at least two different types of device, to maintain skills and competence.15 Practitioners with a LoC IUT need to be re-accredited every 5 years, with yearly appraisals to ensure that skills are retained.15 In practice, clinical governance is often provided by consultants in local contraception and sexual health clinics to ensure that practitioners are trained and competent. The FSRH also stipulates that level 3 services (i.e. those monitoring performance and risk) are led by consultants, with one accredited consultant per 125,000 population to ensure that clinical governance mechanisms are in place across all providers.8

Commissioners need to be alert to and plan for a competent staff mix to deliver IUD/IUS services. The FSRH guidance pays particular attention to ensuring that nurse-led services are also available.8

The NICE cost impact report 6 shows that commissioners will initially have to invest in the training of willing providers, and in making contraception providers fit for purpose for IUD/IUS insertions, to meet minimum standards laid down in NICE guidance.6 Trained staff should be able to ensure that NICE recommendations on providing quality care are achieved at all stages of the referral care pathway, including:2

  • assessing patients’ suitability for IUDs/the IUS against the UK medical eligibility criteria for contraceptive use16
  • discussing a range of contraceptive options, including IUDs/the IUS
  • counselling the patient on modes of insertion, side-effects, and fitting procedure
  • testing at-risk women for sexually transmitted infections (STIs)
    (e.g. chlamydia and gonorrhoea)
    before insertion.

In cases where IUD/IUS fitting is not available (because of a lack of available trained staff), NICE recommends that, particularly in primary care, referral networks should be in place to ensure patients have ‘reasonable’ access to IUDs/the IUS.7

A follow-up appointment within 3–6 weeks of insertion, to check that threads are in place or for post-procedure infection, is also recommended by FSRH guidance.17

The NICE guide for commissioners stipulates that an initial investment will be needed to make IUD/IUS providers ‘fit for purpose’.7 This includes ensuring that:

  • all treatment rooms meet the Care Quality Commission’s standards on infection control
  • specialist equipment is available (for instance, an adjustable couch)
  • protocols are in place for management of possible STIs/pelvic infections and emergencies such as lost threads, or possible uterine perforation.

The FSRH stipulates that two members of staff should be present during fitting of an IUD/IUS: one as a chaperone, if needed and (in the extreme scenario) one in case there is a need for resuscitation. In order to ensure safety, staff need to be trained in cardiopulmonary resuscitation and emergency procedures such as managing cervical shock.17

Auditing outcomes

The FSRH recommends that record-keeping should be kept up to Faculty standards, and that commissioners, along with level 3 service providers, should ensure that monitoring and evaluation mechanisms are in place.8 Both NICE and FSRH recommend ‘regular audits’ (for instance, yearly), to monitor service levels and activity, as well as adverse incidents and responses.2,8

NICE CG30 also recommends other audit measures, which include the:2

  • number of women who have been offered information on contraception, including LARC methods
  • percentage of healthcare professionals advising women about contraceptive choices who receive training and are competent to:
    • help women to consider and compare the risks and benefits of all methods relevant to their individual needs
    • manage common side-effects and problems
  • number of referrals for LARC by providers who are not competent to provide them
  • percentage of healthcare professionals who are trained in LARC methods and who have evidence of ongoing continuous professional development
  • uptake of LARC.

See Box 2 for a summary of recommended audit outcomes from the National Enhanced Services specification for Intrauterine contraception.

Box 2: National enhanced service: intra-uterine contraceptive device fittings—summary of recommended outcome measures12

  • LARC methods prescribed as a proportion of all contraceptives by age
  • Percentage of women who have access to LARC method of choice within x working days of contacting service
  • Percentage of nurses dual trained to deliver contraceptive (including LARC methods) and GUM services
  • Percentage of women having access to and availability of a full range of contraceptive methods.
  • LARC=long-acting reversible contraception; GUM=genitourinary medicine

Conclusion

Demand for and uptake of LARC methods is increasing in England but local authority commissioners need to take active steps to ensure that high-quality services are available to all women who want to use LARC. The use of copper IUDs, in particular, has the potential to deliver substantial cost savings to local areas in terms of averting unplanned pregnancies, and in meeting national public health targets to reduce conception rates in women aged under 18 years. However, commissioners need to pay attention to national service standards to ensure quality, safety, and access to these services.

  • Responsibility for commissioning comprehensive sexual health and contraception services now lies with public health departments of
    local authorities
  • LARC methods are effective and cost effective but uptake is often limited by the availability of competent and willing providers locally
  • If there is insufficient local supply of LARC methods, local authorities may need to consider developing and supporting the local market providers of LARC implants and IUDs/the IUS, possibly by offering training packages
  • Local authorities need to review, respecify, and reprocure any current local enhanced services with general practices before April 2014
  • General practices are well placed to deliver LARC services and to advise on them, but this is not a core part of their contract. Financial incentives offered through local contracts will need to be sufficient to cover the cost of training, equipment, and staffing (including GP time)
  • Local authorities may, however, wish to look beyond general practices and procure LARC services from other providers through open tender or ‘any qualified provider’.

LARC=long-acting reversible contraception

  1. Department of Health. A framework for sexual health improvement in England. London: DH, 2013. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/142592/9287-2900714-TSO-SexualHealthPolicyNW_ACCESSIBLE.pdf
  2. NICE. Long-acting reversible contraception. Clinical Guideline 30. NICE, 2005. Available at: www.nice.org.uk/guidance/CG30 nhs_accreditation
  3. NICE. Heavy menstrual bleeding. Clinical Guideline 44. NICE, 2007. Available at: www.nice.org.uk/guidance/CG44 nhs_accreditation
  4. Health and Social Care Information Centre. NHS contraceptive services, England—2012–2013. Community contraceptive clinics. London: HSCI, 2013. Available at: www.hscic.gov.uk/article/2021/Website-Search?productid=13248&q=NHS+contraceptive+services+England+2012+community+contraceptive+clinics&
    infotype=13367&sort=Relevance&size=50&page=1&area=both#top
  5. Department of Health. Public health outcomes framework for England 2013 to 2016. London: DH, 2012. Available at: www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency
  6. NICE. National cost impact report. Implementing the NICE clinical guideline on long-acting reversible contraception. NICE, 2005. Available at: www.nice.org.uk/nicemedia/live/10974/29916/29916.pdf
  7. NICE. Services for the provision of IUDs and the IUS for contraception and the management of heavy menstrual bleeding commissioning guide. London, NICE: 2008. Available at: www.nice.org.uk/media/815/A0/ServicesForTheProvisionOfIUDsAndTheIUS.pdf
  8. Faculty of Sexual & Reproductive Healthcare. Service standards for sexual and reproductive healthcare. London: FSRH, 2013. Available at: www.fsrh.org/pdfs/All_Service_standards_January_2013.pdf
  9. Department of Health. Commissioning sexual health services and interventions: best practice guidance for local authorities. London: DH, 2013. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/144184/
    Sexual_Health_best_practice_guidance_for_local_authorities_with_IRB.pdf
  10. Department of Health. Standard general medical services contract. London: DH, 2013. Available at: www.gov.uk/government/publications/standard-general-medical-services-contract
  11. NHS Employers. Investing in general practice. The new general medical services contract. DH, London, 2003. Available at: www.nhsemployers.org/SiteCollectionDocuments/gms_contract_cd_130209.pdf
  12. NHS Employers. National enhanced service—intra-uterine contraceptive device fittings. 2003. London: NHS Employers, 2003. Available at: www.nhsemployers.org/SiteCollectionDocuments/nes_intrauterine_contraceptive_cd_130209.pdf
  13. NICE website. Long-acting reversible contraception. Costing template. Clinical Guideline 30. Available at: www.nice.org.uk/guidance/CG30/CostingTemplate/xls/English
  14. Parliament website. Health Select Committee. HC 1048-III Health Committee. Written evidence from the Advisory Group on Contraception (PH 130). Parliamentary copyright, 2011. Available at:
    www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/1048/1048vw123.htm
    (accessed 13 November 2013).
  15. Faculty of Sexual and Reproductive Healthcare website. DFSRH and LoC recertification. www.fsrh.org/pages/DFSRH_and_LoC_recertification.asp (accessed 29 November 2013).
  16. Faculty of Sexual & Reproductive Healthcare. UK medical eligibility criteria for contraceptive use. London: FSRH, 2009. Available at: www.fsrh.org/pdfs/UKMEC2009.pdf
  17. Faculty of Sexual & Reproductive Healthcare. Clinical guidance—intrauterine contraception. London: FSRH, 2007. Available at: www.fsrh.org/pdfs/CEUGuidanceIntrauterineContraceptionNov07. G