The total number of terminations performed in 2009 in England and Wales was 189,100. Each termination is a crisis in that woman's life; a source of unhappiness.
NICE guidelines in 2005 suggested that increasing uptake of intrauterine contraception (IUC)s could help reduce the number of unintended pregnancies. NICE also stated that contraceptive choices should be made accessible to patients from all backgrounds.
If these guidelines are to be implemented there are major implications for primary care and primary care organisations.
For general practice, they mean that every practice needs someone who can offer up-to-date, correct medical advice on all contraceptive methods and ideally, all practices should be able to provide them too. It is easy to guide a woman away from an IUC if there are no facilities or personnel to insert the device.
Obstacles of cost and time
Discussing long-acting reversible contraceptives with women requesting contraception was added to the QOF in 2009 to encourage GPs to offer IUCs. Recently, there was a government drive on television to promote choice of contraceptives.
Some PCTs have responded by providing new, easier ways to get accredited.
Traditionally, the main barriers to setting up an IUC service at the surgery are cost and GP time. Cost is one because of the time spent away from the practice on training. The expense of employing a locum and travel costs can make the initial outlay for a practice quite daunting.
Under the current system, a GP wishing to become accredited needs to obtain a diploma in sexual health from the Faculty of Sexual & Reproductive Healthcare. This requires completing an online theory course followed by practical sessions under an instructing doctor.
But the fall in the numbers of family planning clinics and instructing doctors has resulted in a massive bottleneck and, in some areas, a waiting list of up to two years. On receiving the diploma the GP then has to attend more practical sessions to gain a letter of competence for IUC fitting.
However, things are changing. I have recently been involved in an exciting new project where the PCT, NHS North East Lincolnshire, is taking the lead on accreditation for IUC and implant training. A new training initiative involves a two-to-three hour theory/practical session, followed by two to three sessions of fittings (normally eight to 10 patients) observed by an instructing doctor who will visit the surgery.
This process can be completed within four to 12 weeks. All the PCT's surgeries are being offered the training at no financial cost to individual practices.
The doctor/nurse is then accredited to fit IUCs within that PCT. All doctors and nurses are encouraged to following the faculty route as well.
Even after being faculty-accredited, getting PCT approval for payment to the practice can be a slow process. Two years ago I moved to a single-handed practice of 4,000 patients. Although it did not have an IUC-fitting service, the GP principal was keen for me to start one up. Since I was already an instructing doctor, all that was needed was to apply for PCT accreditation.
The process took 12 weeks, although I have known it to be both a great deal speedier and to take even longer. Some homogeneity in the approval process would go a long way to standardising procedures.
Meanwhile, I got on with staff training. When you are inserting an IUC, I think it is essential to have an accredited healthcare support worker with you.
The support worker is needed to counsel the patient prior to the procedure, for example checking for pregnancy and advising a mild analgesic, and to communicate with and relax the patient during and after the procedure. They can also prepare the equipment, be there to help in the rare case of a vasovagal reaction, book patients in and keep the records.
I trained the healthcare support worker myself. She already had good communication skills and was a quick learner.
Once the surgery had PCT accreditation, we were set to go. All the doctors in the practice were made aware of the new service and once the word got out, patient uptake was very encouraging. In the first year I fitted 50 IUCs - resulting in approximately £5,000 income. IUC fitting is an enhanced service and the PCT pays around £80 per fitting. GPs can also claim prescription costs of around £15 per device.
Having the right tools
To perform IUC insertion and removal correctly, up-to-date equipment is vital. Sometimes dilators or local anaesthetic are needed. I insist on Judd Allis holding forceps, modern dilators, local anaesthetic and a range of speculum sizes.
The reimbursement for fitting and removing an IUC offsets this small cost to ensure that your patient has the most comfortable fitting possible.
Adding a fitting service to the practice was very satisfying. With more promotion of IUCs, availability and easier methods of GP accreditation, more women will be able to choose the contraceptive method that is right for them.
- Dr Walling is a locum GP in Lincolnshire and a family planning doctor in Essex.
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