BEYOND BARRIERS: REIMAGINING ACCESS TO POST-PREGNANCY CONTRACEPTION THE CASE FOR CHANGE
pathway via our local sexual and reproductive health services. This was important for supporting our vulnerable mothers.” Commissioner, Bedfordshire, Luton and Milton Keynes ICB As the Government continues to shift healthcare away from GPs and Emergency Departments into the community and neighbourhood models of care, as outlined in the 10 Year Health Plan, PPC models such as those quoted in this report provide excellent examples of integrating care in the community, and how to prevent avoidable pressure on primary care services and reduce health inequalities. The Existing Barriers Caused by Commissioning Arrangements There was unanimity among contributors that the current commissioning arrangements pose a significant barrier to making this a reality and can often paralyse clinical enthusiasm to offer PPC more routinely. The 2012 Health and Social Care Act transferred the full responsibility for contraception provision in England from the NHS to local authorities, NHS England, and Clinical Commissioning Groups (which have since been subsumed into Integrated Care Systems (ICSs)). Table 1 sets out these commissioning splits:
The impact of these commissioning structures has been devastating for women and contraception service providers alike. For women, care pathways for contraception are disjointed and difficult to navigate - women can be bounced from service to service and may be required to undergo multiple consultations and occasionally multiple intimate examinations when only one is clinically necessary. Women are having to wait weeks, or even months, to access appropriate contraception services. “English commissioning agreements mean that funding for contraception goes only to commissioned providers and does not follow women in their routine contacts with the health service when they might want and need contraception, including maternity.” Northwest London PPC service For service providers, the impact of these commissioning arrangements on PPC services across England is hugely debilitating, as integrated joined up services require clarity, accountability and responsibility – all of which are not provided in this fragmented system.
Table 1: Commissioning of SRH Services in England*
Local Authorities
Integrated Care Boards (ICBs)
NHS England
Contraception under GP contract Pharmacy contraception scheme
Maternity services Gynaecology services (incl. contraception for non-contraceptive purposes) Abortion services, incl. contraception, STI & HIV testing in abortion pathway Female & male sterilisation (vasectomy)
Comprehensive Sexual Health Services, incl. most contraceptive services and all prescribing costs, excluding contraception provided by GPs. LARC provision in primary care (GP) incl. Implants and IUDs/IUSs (for contraception purposes only) Sexual health specialist services incl. youth sexual health, teenage pregnancy services, outreach, HIV prevention, sexual health promotion, services in schools, colleges and pharmacies Support for teenage parents STI testing and treatment, chlamydia screening and HIV testing; partner notification HIV pre-exposure prophylaxis (PrEP) provision (activity, not drug costs) Sexual health aspects of psychosexual counselling
4
4
4
4
4
Cervical screening HPV immunisation
4
4
4
4
Specialist fetal medicine services, incl. late termination of pregnancy for fetal anomaly between 13 and 24 gestational weeks NHS Infectious Disease in Pregnancy Screening HIV testing when clinically indicated in NHSE-commissioned services & treatment Sexual assault referral centres Sexual health elements of prison health services PrEP medication costs
4
4
4
Non-sexual health aspects of psychosexual health services
4
4
HIV/STI testing and STI treatment - if clinically indicated or at the request of a patient. Adult specialist services for people living with HIV
4
4
4
4
4
4
4
4
4
4
Source: Making it work; Health and Social Care Act 2012; Care Act 2014; Health and Care Act 2022; Commissioning local HIV sexual and reproductive health services
Commissioning bodies share budgets and contractual mechanisms to reduce fragmentation and improve outcomes to facilitate simple solutions where capacity, priority, timing and relationships enable this to happen. * The Government has announced that by 2025 NHSE will be brought into the DHSC so future commissioning arrangements are unclear.
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