House of Commons - Health

Select Committee on Health Third Report

7 FAMILY PLANNING AND ABORTION SERVICES

196. The Strategy describes unintended pregnancies and abortion as "a consequence of poor sexual health", and one of its five aims is to "reduce unintended pregnancies".[181] Unintended pregnancy is influenced by a wide range of social and behavioural factors, many which are difficult to map, measure and change. However, inadequate provision of NHS services, whether it be in terms of awkward location, inconvenient opening hours, insufficient choice of provider or method or long waits for appointments, may prevent people of all ages from accessing contraceptive advice and supplies, and therefore contribute to increased numbers of unintended pregnancies and thus abortions.

Current arrangements for commissioning and delivering

197. The provision of contraceptive services is currently divided between GPs, who provide approximately 80% of care, and specialist community family planning clinics, which provide the remaining 20%. According to Dr Connie Smith, Consultant in Family Planning and Reproductive Health Care and Co-Director, Westside Contraceptive Services, Westminster PCT, the current inequitable distribution of community contraceptive provision has developed from the legacy of the clinics taken into the NHS from the voluntary sector Family Planning Association in 1974:

The development of community contraceptive services since then has been determined largely by the work of diverse local champions (including clinicians, service managers, public health physicians) and the interest (or otherwise) of local NHS commissioners. This has resulted in variations producing inequalities in the range, quality and accessibility of service provision across England. The pattern of services does not seem to reflect the pattern of need.[

182

198. Community family planning clinics are staffed by specialist doctors (usually consultants, staff-grade doctors or associate specialists) and nurses, and are funded directly from PCTs, who pay salaries according to sessions worked, as in a hospital clinic. Although GPs are not required to undergo mandatory training in contraceptive and reproductive health, they have strong financial incentives to provide contraceptive services regardless of ability and experience, as they receive feeforservice payments each time they give contraceptive advice.

199. Termination of pregnancy services, where they are available on the NHS, are provided within the obstetrics and gynaecology units of acute hospitals, and women seeking a termination must be referred there either by their GP, or from a family planning clinic. Like community family planning services, NHS abortion services are also subject to significant variation throughout the country. It has been estimated that the percentage of abortions funded by the NHS varies between 46% and 96% in different health authorities. According to the Department, women can wait up to four or five weeks for an abortion in some parts of the country, and the British Pregnancy Advisory Service estimate that waiting times may in fact be up to six weeks in some cases. This can have particularly serious implications for pregnant teenagers, who tend to seek professional advice later than older women. The availability of medical abortion, which can be used early on in pregnancy and avoids the need for anaesthesia and surgery, also varies.

200. With regard to services surrounding unintended pregnancy, the three levels of care proposed by the Strategy will constitute the following:

Level 1

Level 2 (for example primary care teams with a specialist interest in sexual health) - more complex contraceptive services, such as IUD insertion and implant insertion

Level 3 (specialist teams spanning more than one PCT, for example GUM clinics) - outreach contraception, highly specialised contraception, and abortion services.

201. The Sexual Health Strategy Implementation Plan, while promising service standards for treatment of HIV and other STIs and psychosexual problems, does not mention similar standards for contraceptive or abortion services. Instead, it says that "best practice guidance will be published for other sexual health services, including reproductive health services, and services provided in primary care settings."[183] The Implementation Plan does include a section on 'Improving Contraceptive Services', which lists the following measures:

Commissioning Toolkit to provide advice on nurse-prescribing and on ensuring sufficient openaccess provision
Research on effectiveness of free or lowcost condom schemes
Good practice guidance for pharmacists providing emergency contraception
By 2006, NICE will have published guidelines on specific types of longacting contraception.[184]

202. The Commissioning Toolkit, published by the Department in February 2003, devotes several pages to a comprehensive description of best practice in delivering contraceptive services, including ensuring a full choice of methods are available, and that contraceptive advice is complemented by easy referral for pregnancy testing, psychosexual problems, STIs, and immediate access to cervical screening. However, it is not clear whether these are standards for Level 1 or Level 2 service providers to aspire towards. Although the Toolkit specifies that there should be sufficient daytime and evening open-access contraceptive service provision, it does not give maximum waiting time targets, specifying only 'same day attendance'.

203. The Strategy states that abortion services should be developed to provide NHS-funded abortions in line with the Royal College of Obstetrics and Gynaecology guidelines, which recommend:

A central booking service allowing direct access to services
Termination within three weeks
Ideally, a choice of methods
Counselling
Prevention of infection strategy
Contraceptive provision
Follow-up.

204. Moreover, the Strategy specifies that from 2005, PCTs must ensure that women who meet the legal requirements have access to an abortion within three weeks of the first appointment with the GP or other referring doctor. The Implementation Plan contains a section on abortion focused solely on improving access and achieving the waiting time target set by the Strategy. No mention is given in the Standards section to clinical standards for abortion provision, although these guidelines have already been developed by the Royal College of Obstetricians and Gynaecologists.

What impact will the Strategy have?

205. Dr Kate Guthrie, Community Gynaecologist, Hull & East Riding Community NHS Trust described the current separation of contraceptive provision from GUM services as "a ridiculous divide",[185] and most of the other witnesses were supportive in theory of more joined up services. However, Anne Weyman, Chief Executive of the Family Planning Association (FPA), a voluntary organisation which provides advice and community family planning services, argued that the Strategy itself "is not always integrated across the different areas".[186] Dr Sarah Randall, a consultant in Contraception and Reproductive Health from St Mary's Hospital Portsmouth, also suggested that increasing the remit of community clinics to absorb more STI work in addition to contraceptive provision would increase workload in an unsustainable way, and that community specialists would require more time and funding to equip primary care for its new role in the Strategy. The FPA pointed out that although "the new tiered model outlined by the Strategy is designed to promote clarity and consistency for users and providers, the practical implementation presents problems". The FPA flagged up the need for standards at each level to be comprehensively outlined, as well as relationships between levels, and argued that the Strategy failed to take account of the many providers that had not yet acquired the range of services commensurate with Level 1. Our witnesses also identified several major problems related to the Strategy and its implementation.

Lack of priority given by the Strategy to contraception

206. The Public Health Minister told us that although "we want to try and reduce unintended pregnancies across the board" she made "no apology for focusing on teenage parents and young people because the evidence is overwhelming that multi pregnancies in the very early years affect people's life chances right the way through." She went on to qualify this, saying:

I think it is important, however, that older women as well in their 20s, 30s and 40s have access to really good contraceptive facilities. There is a need to make sure that people have the whole range of contraception—not just simply the contraceptive pill—and good advice about what is suitable for them. So I think contraception needs to be highlighted too.[

187

207. The Strategy claims that implementing the NHS Plan's principles in the field of sexual health will mean "lower rates of unintended pregnancies".[188] However, the Strategy gives no detail at all on how the leap from the broad, service-wide reforms outlined in the NHS Plan to actually securing improved outcomes in unintended pregnancy rates, will be made. Indeed, the lack of specific actions, targets or guidance in this area emerged as a key concern in this inquiry. Although the Commissioning Toolkit devotes a section to describing elements of a best practice contraception service, doubts remain over whether or not this is likely to have any impact on the actual priority afforded to contraceptive services by PCTs. Dr Guthrie said that in her view contraceptive services were "progressively becoming the 'poor cousin' in terms of health care provision",[189] and this sentiment of exclusion and deprioritisation was echoed in the reactions of several other service providers to the Strategy:

Strategy

190

Lack of priority at a PCT level

208. While provision of specialist GUM and HIV/AIDS services at secondary and tertiary referral centres is generally accepted as an appropriate model of care, many specialist contraceptive providers feel threatened by what they regard as a widelyheld view that specialist contraceptive clinics are not necessarily needed because GPs also provide contraceptive services.[191] Several memoranda from clinicians working in specialist community services suggest that their work is sometimes seen as a duplication of the services on offer by GPs, but all go on to point to the continuing importance of specialist community clinics, arguing that many GPs do not provide contraceptive services, and those that do may not have the expertise to offer a full range of methods. While GPs may be local and convenient for the majority of people, community clinics provide contraceptive services on an open-access basis, which reduces the bureaucracy that often attends registering with a GP and securing an appointment. Community clinics services are also of particular use for people not registered with a local GP, people whose GPs do not offer contraception, or who only offer a limited range, those with special difficulties in their use of contraception, and of course those who for personal or cultural reasons will not consult their GPs about such a potentially sensitive subject.

209. Anne Weyman for the FPA told us:

192

210. In common with service providers in the fields of GUM and HIV/AIDS, providers of contraceptive and abortion services were also highly concerned about whether, without additional ringfenced funding or NSF status, the Strategy would really have "teeth".[193] Anne Weyman, speaking in her capacity as a PCT board member, argued that "the reality for the PCTs is that these issues are not high priority issues. Teenage pregnancy is on the list but the rest of it is not and there is the question of what is meant by sexual health."[194]

211. According to the Government, the prevention of unplanned pregnancy by NHS contraception services probably saves the NHS over £2.5 billion a year already. Despite this, we have received compelling accounts of disinvestment in these vital services, and the fact that contraceptive services are not even included within the Strategy's five aims is further evidence of this creeping deprioritisation. We recommend that the Government takes immediate steps to rectify this priority imbalance.

Access to services

212. Continuing demand for community family planning services is certainly evident from the concerns voiced by many witnesses from the family planning sector which have striking parallels with those put forward by GUM and HIV/AIDS service providers. Anne Weyman expressed her concern that contraceptive services were 'overloaded', and Dr Sarah Randall, reinforced this view:

It has been a disaster in a lot of areas where clinics have closed. Those that have been left open have increased demands. Certainly around my area you have some clinics which are totally swamped. They have got perhaps four clinic [sessions] trying to deal with what was originally a week's worth of clinics foreshortened.[

195

213. Dr Randall also told us that while GUM services which are run on an appointment basis have this increased demand reflected by their increased waiting lists, in family planning services most are still run on a nonappointment dropin basis, with staff simply having to stay until all the patients have been seen. This means that although services are stretched, instead of increases in demand being exposed by increased waiting lists, they are masked by staff goodwill.

214. Several of our witnesses expressed concern that access problems were likely to be compounded by an impending shortage of specialist consultants and senior medical staff in this area. Dr Randall argued that this may stem from the fact that, unlike GPs and GUM consultants, there is no clearly defined career path for doctors wishing to specialise in contraception and sexual health. Doctors who specialise in sexual and reproductive health are first required to follow a specialist training in general obstetrics and gynaecology. Historical workforce issues have resulted in a shortage of junior doctors in Obstetrics and Gynaecology, meaning that there are fewer trainees to divide between the five subspecialties, of which sexual and reproductive health is one. Priority is obviously given to ensuring cover in highintensity acute areas of the specialty such as labour wards, so most junior doctors in Obstetrics and Gynaecology do not get a chance to do community-based work in sexual and reproductive health. This has a knockon effect on recruitment to senior posts, as fewer juniors are attracted to specialise in this area, having no previous experience in it. Disparities between sessional pay rates for GPs and specialist community doctors (GPs receive £130 for a three hour session while a clinic doctor is paid only £68) may be exacerbating difficulties with recruitment and retention.

Clinical quality and audit

215. Another concern raised with us is that although General Practitioners and their teams provide the majority of NHS contraceptive care, they are not required to undergo mandatory training in this area. The FPA points out that many GPs do not offer the full thirteen methods of contraception, or provide free condoms, and this is not always made clear to patients.[196] GPs are not required to undergo mandatory training in this area, but they have strong financial incentives to provide contraceptive services regardless of ability and experience, and they receive feeforservice payments not related to quality. The FPA argued that this must be recognised and addressed in the new GP contract.

216. The problem of training was acknowledged by Dr Ford, a GP with a special interest in sexual health:

197

217. If General Practitioners are to deliver Level 1 and Level 2 services to a high standard, the Government must ensure that the GP contract addresses issues of quality in relation to provision of contraceptive and other sexual health services, as well as giving GPs incentives to undergo further training in this area. The Government should also work with the relevant bodies to ensure that sexual health is given appropriate emphasis both in undergraduate medical training and in postgraduate education for trainee GPs.

218. Many memoranda also point out that there is a serious shortage of national information currently available about the organisation and provision of contraceptive services. According to Dr Smith, a review of contraceptive services was carried out by the Department at a regional level ten years ago, but the results were never analysed or used to obtain a national picture due to lack of Department of Health capacity. Very little data are available about GP provision of contraceptive services. We recognise the importance of the collection of relevant information for the planning and delivery of services. We therefore recommend that steps are taken to standardise information collection in the field of sexual health, both for specialist service providers and general practitioners.

Abortion services

219. While many witnesses and prochoice lobbygroups have welcomed the inclusion of a measurable target to improve access to abortion services, the FPA argued that "the Strategy's inclusion of a headline target to provide women with an abortion within three weeks of referral will only exacerbate problems caused by an increasing national shortage of consultants, access to GP referral, and inadequate information provision. Women's access is also obstructed by the overbureaucratic procedure—services must be reformed to facilitate selfreferral, and early abortions."[198] The FPA's proposed solution to this was a change in the law to allow an enhanced role for nonmedical health professionals in abortion provision, and to allow more freedom in terms of the settings in which abortions may be carried out. The BPAS went further in arguing that the law should be fundamentally reformed to allow women access to abortion on request within the first 12 weeks of pregnancy.

220. With improved access to better contraception services as part of the implementation of the Strategy, we would hope to see a reduction in the number of unwanted pregnancies, leading to a decrease in the use of the abortion service. For those women who do seek access to the service, we believe that certain improvements should be made. We recognise the difficulties that would beset attempts to reform current laws relating to abortion. However, we support the FPA's view that access targets are meaningless without attendant measures to cut through the bureaucracy surrounding referral for termination of pregnancy. We believe, therefore, that the Government should, within the current legal framework which includes the approval of two doctors, promote a model of open-access for termination of pregnancy, based within Level 3 services, and accessed through a national advice line.

221. We heard compelling evidence that for women who need to undergo an abortion, early medical abortion is a preferable option to surgery, as it carries significantly reduced risk of complications, and can be less distressing. The fact that early medical abortion does not involve any type of surgical process means that, with appropriate training and backup, it could be carried out by nurses rather than solely by doctors, and in community settings rather than solely in acute hospitals. However, at present early medical abortions constitute only a very small proportion of the total abortions carried out. We believe that allowing women access to early medical abortion in a wider range of healthcare settings would help reduce the number of late abortions which may occur as a result of long waits for surgery, and would also be a more cost-effective use of NHS resources. We therefore recommend that the Government should consider this option.

181 Strategy, p 3; p 7 Back

182 Ev 374 Back

183 The National Strategy for Sexual Health and HIV - Implementation action plan, p 13 Back

184 Ibid, p 14 Back

185 Q194 Back

186 Q138 Back

187 Q 112 Back

188 Strategy, p13 Back

189 Q172 Back

190 Q139 (Dr Sarah Randall, Family Planning Specialist) Back

191 See eg Q145 Back

192 Q 145 Back