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 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: Contraceptive method choices after counselling (N=2,500) 1 Long-acting Shorter-acting 33% 67% 69% of year-olds chose a LARC with 63% of these choosing an implant 2

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 and the decrease of conception rates in that age group in England between 1998 and 2011 Adjusted R 2 =0.91 P-value=0.002 ‡ Adjusted R 2 =0.91 P-value=0.002 ‡ * Per 1,000 women aged † In thousand cycles sold ‡ Multiple regression of LARC usage on under 18 conception rates adjusted for time – LARC coefficient estimate =

† 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 AuthorityCCGsNHS 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 questionnaire457 Total number of responses from within England39887% Total number of responses know to be from outside England439% * Total number of responses where location is unknown 164% 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 Figure 2. Professional designation of respondents

PCWHF survey Percentage of responses currently reimbursed for enhanced contraceptive services.

PCWHF survey Enhanced service payment changes:

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