Drs Anne Connolly (left) and Amanda Britton discuss the need to plan for comprehensive contraceptive services in light of the imminent reorganisation of the NHS
- LARC methods are more effective at reducing pregnancy than user-dependent methods. Some women still prefer to choose a user-dependent method because they feel it puts them in control
- All women should be offered a full range of and access to contraceptive methods
- The increased use of LARC, as a result of extra funding to promote training and access, is likely to have played a role in the reduction of teenage pregnancies, since the extra funding was provided to increase training and access to these methods
- PCTs with restrictions to contraceptive choice had higher abortion rates than in those where there were no restrictions on choice of provider, contraceptive method, or to specific women
- 75% of women access contraceptive care from their GP
- It is short-sighted to consider restrictions in service delivery as a short-term financial gain, when every £1 invested in contraception results in a saving of £12.50.
Despite major initiatives over the past decade, the statistics reveal the scale of the challenge ahead for the UK in reducing unwanted pregnancies to the levels achieved in other comparable countries:
- at least 30% of pregnancies in the UK are still unplanned1
- 180,942 abortions were provided by the NHS and NHS agencies in England in 2010.2
The cost of unintended pregnancies to the NHS in England is estimated to be £755 million annually.3 In 2005, NICE estimated that every £1 invested in contraceptive care generates a saving of £11 to the NHS in the costs associated with addressing the consequences of unplanned or unwanted pregnancy;1,4 this figure has recently been revalued as a £12.50 cost saving.3
The output of a recent inquiry by the All-Party Parliamentary Group (APPG) on Sexual and Reproductive Health in the UK, titled Healthy women, healthy lives—the cost of curbing access to contraception services, described restricted access to contraceptive provision in specific regions of the UK and urged action to resolve inequalities.5 There is also a significant risk that the challenge to find £20 billion of efficiency savings by 2015, which coincides with the large-scale commissioning changes planned for the NHS from 2013, will make it exceptionally difficult to address these restrictions and to bring UK performance in line with its neighbours. As the new commissioning arrangements become embedded, there is a particular risk of fragmentation of responsibility for contraceptive care as the funding for service delivery becomes divorced from the consequences of failure to deliver.
Long-acting reversible contraception
There is widespread agreement that increasing use of long-acting reversible contraception (LARC) in women at all stages of their reproductive lives is a vital component of the strategy to reduce unwanted fertility. Improving both access to and provision of LARC methods was recommended by the 2005 NICE guideline on LARC,1 which highlighted that these contraceptive methods were both more effective and cost efficient when compared with the most popular user-dependent methods. Long-acting reversible contraceptive methods consistently achieve superior efficacy by reducing user error. The LARC methods have failure rates between 0.005% and 0.5%, and are at least as effective as male sterilisation and better than female sterilisation; in comparison the user dependent combined oral contraceptives and condoms have failure rates of 8% and 15%, respectively.1,6
Primary care teams were incentivised to promote LARC methods when contraception was included as a new clinical domain in the 2009/10 quality and outcomes framework (QOF).7 A total of 10 points is available for those teams that demonstrate they provide information about LARC methods as part of routine and emergency contraception requests.
Four effective LARC methods are currently available:
- copper intrauterine devices (IUDs)
- the intrauterine system (IUS)
- the contraceptive subdermal implant (SDI)
- progesterone-only injectable contraceptives.
All of the LARC methods, with the exception of progesterone-only injectables, require additional training to acquire the necessary skills to select and counsel patients, and to insert and remove the devices correctly.
Recent evidence from the US Contraceptive CHOICE project has demonstrated that if women, particularly young individuals, are offered information about different contraceptive options, with emphasis on the superior effectiveness of LARC methods, and access to a full range, at no financial cost to the user, over two-thirds will choose to use a LARC method.8 A significant reduction in teenage birth rates and abortions was observed in the CHOICE cohort who opted for a LARC method; the teenage birth rate was 6.3 per 1000 compared with the US rate of 34.3 per 1000 and the abortion rate was less than half the regional and national abortion rates.9,10
UK trends in contraception provision and uptake
The Department of Health provided extra funding to those PCTs that agreed to improve access to LARC training or service delivery under service-level agreements or under practice-based commissioning as locally enhanced agreements, between 2008 and 2011. These important initiatives are very likely to have been significant in the reduction of teenage conceptions—currently at the lowest rate for 40 years (35.4 per 1000 in those aged 15–17 years).11
The use of LARC methods has increased year on year, particularly in younger women, but accounts for only 12% of all women using contraception.12
Despite the change in trends, a Freedom of Information Audit performed in 2012 found that 35% of PCTs, between them serving a population of 3.2 million women of reproductive age (15–44 years), were not providing fully comprehensive contraceptive services.13 This apparent ‘postcode lottery’ of contraceptive provision may explain the average abortion rates in 2010, which at 20.4 per 1000 resident women was higher in the areas of poorer provision than the national average of 18.6 per thousand women. Concerned by these audit findings, the APPG on Sexual and Reproductive Health in the UK undertook an inquiry to explore the findings of this audit and collect evidence from clinicians, patients, and commissioners. The results of the inquiry raised concern about huge variation in service delivery across the country; some areas:5
- provided no contraception for patients via GPs
- described services that were restricted to young people only
- restricted services to patients residing within the PCT area—deliberately excluding commuters
- required a GP referral to the community contraceptive service requesting provision of LARC
- reported a huge variation in primary care enhanced service payments for LARC.
The APPG inquiry concluded that it is: ‘... a fundamental right of all women and men to have access to a full range of contraception and contraceptive services, including information and advice that enables them to choose the method which is best for them ... Any restrictions on access on the basis of age, residence or method should be removed as a matter of urgency.’5
NHS reorganisation and its impact on contraception provision
The reconfigured responsibilities for commissioning and governance as a consequence of the reorganisation of the health service from 2013 are shown in Table 1 (see p.19).14
The majority of contraception and sexual health commissioning responsibility will be transferred to the Local Authority. The NHS Commissioning Board will be commissioning core primary care contraceptive provision, and the consequences of poor sexual and reproductive health will remain with the clinical commissioning groups (CCGs). The latter includes abortion care, chronic pelvic infection, chronic pelvic pain, and fertility problems.
The challenges arising from such a reorganisation are that with this fragmentation of commissioning, the accountability of contraceptive provision is threatened as the funding for service delivery is separated from the consequences of getting it wrong.
Reducing unplanned pregnancy in young women will continue to be an important target in the ‘new world’ and it is one of the public health outcomes as outlined in the Department of Health document, Healthy lives, healthy people. 15 Teenage pregnancy is both a cause and result of exclusion, poverty, and inequality, and results in poor outcomes for both pregnancy and future opportunities for the teenage parent and baby; however, focusing on teenage pregnancy may increase the risk of neglecting the needs of women aged 20 years and over, through disinvestment in service provision for them. The fact that 80% of abortions provided in 2010 occurred in women aged over 20 years2 demonstrates the importance of effective contraceptive care for this group of individuals.
Will local authorities have the vision, agility, and capacity to consolidate and develop GP enhanced services for LARC? Failure to do so could compound problems in those areas where primary care provision of LARC services has been established at the cost of gradual reduction in community clinic provision and this may prove difficult to reverse. This potential loss in primary care provision would further reduce choice and access for women, many of whom prefer to access their contraceptive care from their GP. There is also a risk of losing a skilled workforce if these ongoing arrangements are not confirmed soon.
Despite these concerns, the planned changes provide opportunities to reduce unnecessary expenditure by:
- using detailed local needs assessments to identify the concerns of the local population and ensure the right services are delivered in the right place at the right time. The sexual health balanced scorecard is a useful resource to help and is updated on an annual basis16
- giving commissioners the confidence to invest in contraceptive provision with the knowledge that there is a £12.50 saving for every £1 spent; however, this is a global NHS benefit rather than a local one
- providing opportunities for collaborative working—however, these come with an expectation that Health and Wellbeing Boards are involved to ensure full and easy access to such services for all
- aiming to streamline healthcare professional access to training in sexual and reproductive health and the fitting of LARC devices, as a result of a joint-working agreement between the Faculty of Sexual & Reproductive Healthcare and Royal College of General Practitioners.17
|Department of Health||
|NHS Commissioning Board||Commissioning of:
|Public Health England||Development of:
|Clinical commissioning groups||Commissioning of:
|Local Authorities||Commissioning of:
There remains an urgent need to improve contraceptive care in the UK. This is a public health concern as current systems often fail in areas of higher deprivation because of lack of knowledge, access to services, and provision of choice of contraceptive methods, including LARC. Recent work from a highly deprived area of the US has demonstrated that such a scenario is possible.8,9
Not all women will choose LARC and it may not be appropriate for them to do so, but they should be allowed the opportunity to make that choice with sufficient information, access to provision, and to a trained healthcare professional. This must remain an option for all women whatever their age or postcode.
There is pressure on future commissioners to ensure that the contraceptive needs of local populations are served by an appropriate number of trained healthcare professionals. Funding must be prioritised and made available to support these aims, and not be lost in the many other demands imposed on local-authorities finances.
In this time of upheaval for the NHS we do have opportunities to make cost efficiencies and to improve care but with the fragmentation of commissioning responsibilities for sexual and reproductive healthcare, women’s needs must not be neglected.
Future challenges for healthcare professionals and commissioners include:
- keeping up to date with local future service delivery especially if any restrictions to services or methods are planned or local enhanced services are threatened
- establishing streamlined local pathways of care to specialist services that are easy and accessible for all women
- managing contraception as part of holistic healthcare for women—contraception is not someone else’s business.
- The responsibility for commissioning contraceptive services will potentially be fragmented in the new NHS
- Through local health and wellbeing boards, CCG leads need to agree a strategy with local partners in education and public health to address teenage and unwanted pregnancy rates
- CCG leads should meet with representatives of the NHS Commissioning Board and public health colleagues to ensure a comprehensive contraceptive and sexual health service is commissioned based on this strategy
- Commissioners should consider effective incentives to encourage general practice to obtain training in LARC and to offer LARC methods to women
- Commissioners could look to use the Any Qualified Provider programme to commission contraceptive services from a range of different providers if local general practice providers struggle to meet demand.
- National Institute for Health and Care Excellence. Long-acting reversible contraception. Clinical Guideline 30. London: NICE, 2005. Available at: www.nice.org.uk/guidance/CG30
- Department of Health. Abortion statistics, England and Wales: 2010. London: DH, 2011 available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH 126769
- Bayer Healthcare Pharmaceuticals. Contraception atlas 2011. Bayer Healthcare Pharmaceuticals, 2011.
- Hughes D, McGuire A, Walsh J, Wareing J. The economics of family planning services. London: Family Planning Association, 1995.
- All-Party Parliamentary Group on Sexual and Reproductive Health in the UK. Healthy women, healthy lives? The cost of curbing access to contraceptive services. London: APPG on Sexual and Reproductive Health in the UK, 2012. Available at: www.fpa.org.uk/campaignsandadvocacy/advocacyandlobbying/all-party-groups-on-sexual-health/appg-uk
- Hughes D, McGuire A. The cost-effectiveness of family planning service provision. J Public Health Med 1996; 18 (2): 189–196. Available at: jpubhealth.oxfordjournals.org/content/18/2/189.full.pdf
- British Medical Association, NHS Employers. Quality and outcomes framework guidance for GMS contract 2009/10. London: BMA, NHS Employers, 2009. Available at: www.nhsemployers.org/aboutus/publications/documents/qof_guidance_2009_final.pdf
- Secura G, Allsworth J, Madden T. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol 2010; 203 (2): 115.e1–e7.
- Winner B, Peipert J, Zhao Q et al. Effectiveness of long-acting reversible contraception. N Eng J Med 2012; 366 (21): 1998–2007.
- Peipert J, Madden T, Allsworth J, Secura G. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012 (epub ahead of print).
- Office for National Statistics website. Conceptions in England and Wales, 2010. www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and-wales/2010/2010-conceptions-statistical-bulletin.html (accessed 17 December 2012).
- NHS Information Centre. NHS contraceptive services: England, 2011/12. Community Contraceptive Clinics. NHS Information Centre, 2012. Available at: www.ic.nhs.uk/pubs/nhscontra1112
- Advisory Group on Contraception. Sex, lives and commissioning. An audit by the Advisory Group on Contraception of the commissioning of contraceptive and abortion services in England. Advisory Group on Contraception, 2012. Available at: cleregolfserver.co.uk/bayer/sex-lives-and-commissioning/index.html
- The Stationery Office. Health and Social Care Act 2012. London: The Stationery Office, 2012.
- Department of Health. Healthy lives, healthy people: improving outcomes and supporting transparency. London: DH, 2012. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358
- Public Health Observatories website. Sexual health balanced scorecard. www.apho.org.uk/default.aspx?QN=SBS_DEFAULT (accessed 17 December 2012).
- Faculty of Sexual & Reproductive Healthcare, Royal College of General Practitioners. Joint statement by the Royal College of General Practitioners and the Faculty of Sexual & Reproductive Healthcare on the provision of training in sexual & reproductive healthcare. Available at: www.fsrh.org/pdfs/JointRCGP_FSRHstatementTrainingSRH.pdf G