Posted 30th Jul 2013
The excellent eFeature by Justine Womack last month gave a clear overview of the improvements in sexual health outcomes that have been achieved in this country over the past decade, driven by the concerted efforts of politicians, healthcare providers in the NHS and private organisations, and the voluntary sector. Latest figures demonstrate continued reductions in teenage conception rates in most areas as well as a reduction in abortions. There have been many reasons for these improvements, including: access to provision of free contraception by a choice of provider; availability of new contraceptive products; more reliable methods in the form of the long-acting reversible options; and better education about sexual and reproductive health.
Since April 2013 commissioning responsibilities for contraception and sexual health have changed. The majority of contraception (including enhanced services in primary care) is now commissioned as part of sexual health under the remit of public health in local authorities. The commissioning of termination of pregnancy and gynaecology services is the responsibility of the newly formed Clinical Commissioning Groups (CCGs), while core primary care contraceptive provision and HIV treatment are commissioned by NHS England.
There are advantages to the new public health commissioning arrangements as the emphasis for improving health outcomes (including in obesity and smoking cessation) is moved towards prevention and screening. The new arrangement also increases responsibility at local authority level for ensuring sexual health education in schools is prioritised and improved.
A real concern however, is the risk of fragmentation of responsibility and accountability for contraceptive care as the funding for service delivery becomes separated from the consequences of failure to deliver. For example, the pressure on making savings by local authorities, if applied to contraceptive services, might inadvertently result in increased costs from poorer health outcomes to the CCGs, in the shape of greater need for abortion care and acute gynaecology admissions with pelvic infection and longer term problems associated with tubal damage and subfertility.
Economic evaluation has demonstrated that contraceptive services are highly cost-effective and that the adequate funding and provision of all methods is a cost-saving measure[i]. Yet, a fairly recent audit of the commissioning of contraceptive and abortion services in England[ii] revealed a stark picture of inequality, with as many as 3.2 million women of reproductive age (15-44) living in areas where fully comprehensive contraception services were not provided. Restrictions included access to services and contraceptive methods. The areas with poorer provision had worse outcomes with higher abortion rates than the national average.
As the new commissioning arrangements become embedded there are some key issues to consider. Firstly, Long Acting Reversible Contraception (LARC) provision must continue to be an important part of future service delivery. The US Contraceptive CHOICE project demonstrated significant reduction in teenage birth rates and abortions in those opting for a LARC method, with a teenage birth rate in the CHOICE cohort of 6.3 per 1000 compared with the US rate of 34.4 per 1000 and an abortion rate of less than half the regional and national abortion rates[iii].
As 75 per cent of women continue to access their contraceptive care from their GP, the provision of LARC by primary care must remain a priority and the contracting of this service (complicated as the arrangements may be) is essential if the improvements in recent years are to carry on.
Secondly, sexual health provision is the largest clinical service local authorities are required to commission. LA commissioners will need the vision, flexibility and confidence to continue to develop GP enhanced services. There is a risk that lack of clinical expertise may limit understanding of the complexity of sexual health and contraception service delivery, and the need to provide open access services, from a variety of providers offering a full choice of both clinic types and contraceptive methods. Some women prefer to attend their own primary care clinic for this care, others prefer the easy access and anonymity of a clinic provided in a central site near their workplace. It will remain important to provide a choice without imposing barriers due to the complexities of contracting and funding agreements.
Thirdly, standards of service delivery and future training also need some continued attention. Joint work between the Faculty of Sexual & Reproductive Healthcare (FSRH) and Royal College of General Practitioners (RCGP) has been ongoing to improve the access to training and increase training providers and the numbers of clinicians trained to insert LARC and manage any complications. It is important, if the market place becomes more competitive, that the future of training is not threatened; and that changes in primary care provision and funding do not cause a reduction in training opportunities and the number of skilled providers.
CCG boards are currently making massive decisions about future strategies and services, which are dominated by cardiovascular disease and cancer services. Many feel that they do not need to be involved or concerned with the future of contraception and sexual health services with the delegation of responsibility to local authorities. Health and wellbeing boards are still busy being established and have huge agendas. Women are too embarrassed to complain about poor sexual health and contraceptive service provision. If we want to protect and improve the services we are delivering in primary care then it is important we do so now before future contracts are decided without clinical input and the skills for providing enhanced services are lost. It is important that concerns are raised at CCG board level or with Local Medical Committees (LMCs) now.
The Primary Care Women’s Health Forum, of which I am the Chair, is also collecting information about what is happening around the country, to monitor the impact of changes on service provision. If you have any concerns or your local services are changing we are keen to hear on firstname.lastname@example.org. For further information on the work of the Forum or to register for free membership go to www.pcwhf.co.uk
[i] Hughes D, McGuire A, Walsh J, Wareing J, The economics of family planning services. London: fpa, 1995
[ii] Sex,lives and commissioning: An audit of the commissioning of contraceptive and abortion services in England. Advisory Group on Contraception (AGC), April 2012
[iii] Winner B, Peipert J, Zhao Q et al. Effectiveness of long-acting reversible contraception. N Eng J Med 2012;366 (21):1998-2007
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