Concerns about the future of LARC provision in primary care

Dr Anne ConnollyGP

Clinical Specialty Lead for maternity, women’s and sexual health; Bradford City, Bradford Districts and AWC CCGs

Chair of the Primary Care Women’s Health Forum

Contraceptive Choice Project

LARC=long-acting reversible contraceptive.1. Secura GM et al. Am J Obstet Gynecol. 2010;203:115.e1–115.e72. Mestad et al. Contraception 2011;84:495-8.

Contraceptive method choices after counselling (N=2,500)1

Long-actingShorter-acting

33%

67%

69% of 14-17 year-olds chose a LARC with 63% of these choosing an implant2

Contraceptive Choice Project

Winner et al. N Eng J Med 2012

Pill Patch Ring

Evaluation of long-acting reversible contraceptive use, teenage pregnancy and abortion rates in England - is there an association?Connolly A, Pietri G, Yu J, Humphreys S (awaiting publication)

A statistically significant association was observed between the increase of LARC usage in women aged 15-17 and the decrease of conception rates in that age group in England between 1998 and 2011

Adjusted R2=0.91P-value=0.002‡

Adjusted R2=0.91P-value=0.002‡

* Per 1,000 women aged 15-17† In thousand cycles sold‡ Multiple regression of LARC usage on under 18 conception rates adjusted for time – LARC coefficient estimate = -0.0104

† P-values for rate of change over time‡ P-values for the association between the rate change and LARC usage

Evaluation of long-acting reversible contraceptive use, teenage pregnancy and abortion rates in England - is there an association?Connolly A, Pietri G, Yu J, Humphreys S (awaiting publication)

Commissioning changes

Local Authority CCGs NHS Commissioning Board

•Enhanced contraception services provided by primary care, including device costs

•STI testing and treatment•Chlamydia screening•HIV testing•Sexual health aspects of psychosexual counselling•Sexual health specialist services including young people’s services, outreach, sexual health promotion, services in schools and pharmacies

•Abortion services

•Gynaecology including contraception for non-contraceptive purposes

•Sterilisation•Non- sexual health elements of psychosexual services

•Contraception provided as additional service in primary care

•HIV treatment and PEP costs•Sexual health in prisons•Sexual Assault Referral Centres•Cervical screening

What are our challenges?

• Priorities – keeping contraception on the agenda• Trained clinicians – and future proofing• Funding – ring fenced until 2016 and then?• Commissioning – new, non-clinical commissioners• Communication - new teams• Planning – ‘procurement rules’ • Commissioning of contraception for non-

contraceptive purposes – HMB pathways

PCWHF survey

• The purpose of the survey was to obtain a snap shot of the state of Women’s Sexual and Reproductive Health Care Provision across England, and to ascertain any impact that the new commissioning arrangements may be having

PCWHF survey

• What is your role?• Which CCG do you work in?• Are you involved in commissioning?• Are you currently reimbursed for a contraceptive enhanced service? • Are you currently reimbursed for a sexual health enhanced service? • Did you have an enhanced service where funding stopped in April 2013?• Do you know if your contract for enhanced service provision ends in April

2014?• Have you seen any other changes to your local contraceptive service?

PCWHF survey

Frequency % of Total

Total number of responses to questionnaire 457

Total number of responses from within England 398 87%

Total number of responses know to be from outside England 43 9%

*Total number of responses where location is unknown 16 4%

Table 1. Response to Survey:*answers to question 2 of survey “Which CCG do you work in” either not completed, or information not sufficiently specific to determine if located within

England.

representing 72% (151/211) of the English CCGs.

PCWHF survey

0.8%

74.6%

10.0%

14.1%

0.5%

Missing data

GP

Nurse Practitioner

Practice Nurse

Other

Figure 2. Professional designation of respondents

PCWHF survey

70.00% 75.00% 80.00% 85.00% 90.00%

Reimbursed for both IUD/S and Subdermal implant fitting

Reimbursed for Subdermal Implant fitting

Reimbursed for IUD/S fitting

Percentage of responses currently reimbursed for enhanced contraceptive services.

PCWHF survey

• Enhanced service payment changes:

0% 10% 20% 30% 40% 50% 60% 70% 80%

Missing data

Unsure

No

Yes

Known that funding for advanced service is ending in April 2014

PCWHF survey• Multiple different enhanced services and payments• Confusion about current/future changes• Few providers involved with commissioning decisions• Lack of direction• Reduction in services• Training implications• Planning implications• Poor communication between Public Health

commissioners and providers

PCWHF survey

• Concerns:– What happens to older women >25– What happens to recharging– Where are LARC device costs– Heavy Menstrual Bleeding pathways– Cervical cytology– Choice of providers– Clinical governance– Training

PCWHF surveyRecommendations:

Better communication between the new commissioners and providers so that they can plan, organise training and develop new clear pathways for future service delivery (including for non-contraceptive use of LARC)

CCGs must be kept informed of service changes via the Health and Well Being Boards. The risk of service delivery becoming less accessible or acceptable could have an impact on extra costs to the CCG in TOPs and gynaecology referrals

Thank-you

anne.connolly@bradford.nhs.uk