Posted 11th Nov 2015
Who should services serve?
How to provide a service that meets the needs of both clients and commissioners is already a challenge, which the current tough climate is about to make worse. Mid and North East Essex has become the first clinical commissioning group (CCG) to stop funding IVF treatment. Newspapers have reported that at least three other CCGs are cutting the number of funded cycles on offer, and some will already only fund treatment in “exceptional circumstances”, such as when one partner is undergoing cancer treatment. There is no evidence base for these cuts but, frankly, some commissioners don’t seem to care. The National Institute for Health and Care Excellence (NICE) still recommends up to three cycles of IVF for women under 40 who have not conceived after two years but when purse strings tighten, compromises are made.
Will abortion services be next? The almost universal state funding of abortion services is relatively new. Until the 1990s a significant proportion of women were expected to fund their own abortions. Women seeking treatment to terminate a pregnancy were in exactly the same position that women seeking treatment to start a pregnancy will be in: a “post code lottery” justified by cost.
The answer is probably not. Strong public health arguments back social provision of abortion. Forcing a woman to have a child she doesn’t want is potentially damaging to her mental health, and the stability of her family life (which, after all is why so many are legally provided). Even most conservative politicians recognize that contraception sometimes fails and sometimes we fail to use it. Pretty much everyone agrees that it’s best when families are planned and children are wanted. An unwanted birth is seen as a social problem, whilst the absence of a wanted birth is private grief.
So while Governments want to reduce spending on welfare, moralise about parental responsibility and insist that people try harder to live within their means, abortion services will probably escape the axe faced by assisted conception. When there is a cost effective case for women’s choice it is likely to remain on the table, when there isn’t it won’t even appear on the menu. Of course, in reality this means, when it comes to NHS services, women’s choice is limited.
The challenge for those trying to provide commissioned services, is how to provide the best possible services at the lowest possible cost – especially in areas such as termination of pregnancy where competition for contracts exists, but tariffs have never applied. The Commissioner, picks a price, goes out to tender, and providers scramble to meet the cost. During one recent competitive tender one provider, presumably keen to demonstrate its efficiency, even inquired whether it was possible to bid at a lower than bid price.
Maintaining quality of care while driving costs down requires creativity and attention to what really matters to women. This is made more difficult because what matters to women, is not always what matters to commissioners – who come, as in other areas of work, with different amounts of knowledge, interest and insight into what we do.
Over the last decade many commissioners have really come to understand what a good abortion service looks like, others have no clue at all. Many try their hardest to use the evidence-based guidelines. But the simple fact is, there is no common standard. There is currently no agreed specification for services, no consensus on reporting requirements, and the model contracts (and even commissioning tools) that apply to NHS services generally, are weirdly mis-matched to abortion services.
The previous standard service specification for abortion services and model contract developed by the Department of Health (DH) with the engagement and collaboration of providers was abandoned with the restructuring of commissioning. Because this focused specifically on what women needed from the service it was able to sew up gaps between contraceptive services, STI testing and treatment, and termination of pregnancy services. For example, the inclusion of the provision of long-acting reversible contraception (LARC) as an official expectation in the “paperwork” made clear that commissioners should commission it, and providers should provide it. Today, there is no central agency with an overarching interest in defining “what is good”, the obvious risk being that commissioners make it up as they go along.
Right now, abortion services may enjoy protection because of political fears of what would happen if they were to be dealt the fate of infertility services, but that is no guarantee for the future. We owe it to clients to provide sustainable quality of care and we owe it to the NHS to provide abortions that cost no more than is necessary to do that. Since for-profit providers are fringe players in the commissioning game, the answer cannot be a race to offer the lowest price, which must inevitably lead to less training, education and governance. What is really required is a national conversation about what a good abortion service will look like between now and 2020, and what it will cost.
Women’s needs are not complicated:
They want easy access to an appointment;
They want local treatment when treatment is in early pregnancy but are content to travel a reasonable distance for later procedures, general anaesthetic, or some extra specialist care;
They want appointments at convenient times and the on a date that allows them to make arrangements;
They want assurance that the clinic service is safe and regulated, supported and informed;
They want the clinic to be friendly and kind and confidential and able to offer whatever support or counseling they want throughout their treatment;
They want to know they will receive whatever after-care support they need.
There is not a single abortion provider that does not wish to meet those standards and we should all be able to do this with good values, in a way that provides good value for money.
Abortion care must remain part of an NHS framework, and our challenge for 2016 is to find ways to collaborate to keep it there.
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