Concerns about the future of
LARC provision in primary care
Dr Anne Connolly
GP
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
Contraceptive method choices after counselling (N=2,500)1
Long-acting
Shorter-acting
33%
67%
LARC=long-acting reversible contraceptive.
1.
Secura GM et al. Am J Obstet Gynecol. 2010;203:115.e1–115.e7
2.
Mestad et al. Contraception 2011;84:495-8.
69% of 14-17 year-olds chose a LARC with 63% of
these choosing an implant2
Contraceptive Choice Project
Pill Patch Ring
Winner et al. N Eng J Med 2012
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)
Adjusted R2=0.91
P-value=0.002‡
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
* 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
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)
† P-values for rate of change over time
‡ P-values for the association between the rate change and LARC usage
Commissioning changes
Local Authority
CCGs
•Enhanced contraception
services provided by primary
care, including device costs
•Abortion services
•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
NHS Commissioning Board
•Contraception provided as
additional service in
•Gynaecology including primary care
contraception for nontreatment and PEP costs
contraceptive purposes •HIV
•Sexual health in prisons
•Sterilisation
•Non- sexual health elements of
psychosexual services
•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 noncontraceptive 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%
representing 72% (151/211) of the English CCGs.
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.
PCWHF survey
0.5%
0.8%
14.1%
Missing data
10.0%
GP
Nurse Practitioner
Practice Nurse
Other
74.6%
Figure 2. Professional designation of respondents
PCWHF survey
Reimbursed for IUD/S fitting
Reimbursed for Subdermal
Implant fitting
Reimbursed for both IUD/S and
Subdermal implant fitting
70.00%
75.00%
80.00%
85.00%
90.00%
Percentage of responses currently reimbursed for enhanced
contraceptive services.
PCWHF survey
• Enhanced service payment changes:
Known that funding for advanced service is
ending in April 2014
Yes
No
Unsure
Missing data
0%
10%
20%
30%
40%
50%
60%
70%
80%
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 survey
 Recommendations:
 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