HC 1048-III Health CommitteeWritten evidence from the Advisory Group on Contraception (PH 130)

1. Executive Summary

1.1 The Advisory Group on Contraception (AGC) is pleased to have the opportunity to contribute to the Health Select Committee’s inquiry on public health. The AGC is made up of leading clinicians and advocacy groups that have come together to discuss and make policy recommendations concerning the contraceptive and sexual health needs of women. Given the current policy focus, which has been skewed towards teenagers, the AGC has decided to focus on post-teen women to ensure that the contraceptive needs of all women, whatever their age, are met. A full list of members of the AGC is available in Appendix 1.

1.2 We believe that comprehensive, open access sexual and reproductive health services play an important part in delivering improved public health by preventing ill health, improving wellbeing and addressing inequalities. It is therefore crucial that improvements in sexual and reproductive health services are given adequate focus and attention within the new public health service, and during the Committee’s inquiry.

1.3 In particular, we believe it is crucial that open and equal access to sexual and reproductive services is maintained and that people are able to have a genuine choice in the services and types of contraceptives available to them.

1.4 We have provided evidence to the areas where we feel able to constructively contribute the most to the inquiry and would like to make the following recommendations in our submission:

1.4.1Local sexual and reproductive health advisory groups should be established to bring together providers and specialist healthcare professionals to advise NHS and public health commissioners.

1.4.2Public Health England should take steps to put in place safeguards to ensure the ring-fenced public health budget is spent on appropriate public health initiatives.

1.4.3The Department of Health should take steps to ensure the establishment of a sexual health tariff for contraception services as soon as possible.

1.4.4Public Health England should set out plans to develop national frameworks for the commissioning of effective public health services.

1.4.5Public Health England should regularly review the quality of the indicators selected and carry out research to identify those indicators which will be best suited to deliver on the principles set out in the Public Health White Paper.

1.4.6Public Health England should consider the use of Patient Reported Experience Measures (PREMS) in reporting outcomes for public health services, including sexual health and reproductive services.

1.4.7Information on the number of healthcare professionals trained to fit and remove different types of long-acting reversible contraception (LARC) should be collected by health professionals’ regulatory bodies and reviewed by Public Health England to ensure that there is sufficient provision in all parts of the country.

1.4.8Public Health England should work with relevant stakeholders to establish national standards of competency for healthcare professionals delivering contraceptive services.

1.4.9The Department of Health should provide clarification on how workforce training for public health services will be funded within the new structures.

1.5 Should you require any further clarification please do not hesitate to contact our secretariat. The meetings of the Advisory Group on Contraception have been organised and funded by Bayer. The secretariat for the AGC is provided by MHP Communications, whose services are also paid for by Bayer.

2. Future Role of Local Government

2.1 While the AGC supports the devolution of responsibilities for public health to ensure that services are responsive to the needs of local communities, we believe that an important role remains at a national level for Public Health England and the NHS Commissioning Board in ensuring that local authorities are supported in commissioning high-quality integrated, comprehensive services for sexual and reproductive health.

2.2 Public Health England should be responsible for establishing national models for contraceptive pathways which could then be tailored by local authorities to the needs of their area. It should be the duty of Directors of Public Health to ensure that comprehensive and integrated sexual and reproductive services are commissioned and that referral pathways between them are in place.

2.3 Under the public health reforms, health and wellbeing boards and the proposed clinical senates will have an important role to play in ensuring that there is effective co-ordination between community contraceptive services commissioned by local authorities and contraceptive services commissioned by the NHS Commissioning Board and provided in general practice. That is why it is important that there is adequate clinical involvement in health and wellbeing boards.

2.4 We would ask the Committee to consider recommending that sexual and reproductive health advisory groups and clinical networks are well established in each local area, bringing together providers and specialist healthcare professionals to advise GP commissioning consortia, Directors of Public Health and health and wellbeing boards on the commissioning of sexual and reproductive health services.

2.5 We would ask the Committee to consider recommending that local health and wellbeing boards hold patient stakeholder events to understand the population’s needs and preferences.

2.6 The Joint Strategic Needs Assessment (JSNA) will be an important duty of health and wellbeing boards. Health and wellbeing boards should have access to the following information on sexual and reproductive health in order to undertake a comprehensive JSNA which will underpin effective commissioning decisions:

2.6.1Public health surveillance data.

2.6.2Outcome indicators.

2.6.3Patient experience information.

2.6.4Financial data.

2.6.5Data on the quality of existing services.

2.6.6Governance information.

3. Arrangements for Commissioning and Funding Public Health Services

3.1 The AGC supports the proposal to ring-fence public health spending from within the overall NHS budget. Our experience has been that in the past the additional funding for improving contraceptive services allocated to PCTs has not been protected and it has therefore been hard to monitor the deployment and outcomes of this funding. We also believe that the health and wellbeing board is the correct place to bring the ring-fenced public health budget together with other relevant local authority budgets.

3.2 We believe there will need to be adequate safeguards in place to ensure that the devolved ring-fenced public health budget is spent on true public health initiatives and is not used to subsidise other areas of local authority responsibility.

3.3 The Committee should consider recommending that Public Health England takes steps to put in place safeguards to ensure the ring-fenced public health budget is spent on appropriate public health initiatives, including clinical initiatives.

3.4 Public Health England will play an important role in ensuring the effective use by local authorities of public health funding by providing data to allow an analysis of the link between spending and outcomes. This will help to highlight the savings that can be achieved from investment in contraceptive services—including LARC methods—while at the same time support the health service in meeting the £20 billion of efficiency savings required by 2015. For example, it is estimated that every £1 spent on contraceptive services saves the health service £11.

3.5 To ensure that quality services are able to achieve good levels of investment we would advocate for the use of tariffs rather than block contracts. This will help to incentivise good quality services which achieve the desired outcomes for patients and users.

3.6 The establishment of a tariff for sexual health services must be completed without delay in order to safeguard quality as the Department of Health’s principle of any willing/qualified provider. We are concerned at the delay in the development of the sexual health tariff and urge the Department of Health to ensure that it is finalised and implemented at the earliest opportunity. In order to ensure that the quality of sexual and reproductive health services is protected we believe it is important that the sexual health tariff is set at a fixed price, rather than a maximum, and that willing providers should compete on quality. The tariff should also make provision for cross-border recharge and increase patient choice about where they receive service provision.

3.7 The Committee should consider recommending that the Department of Health take steps to ensure the establishment of a sexual health tariff as soon as possible and that the points raised above are taken into consideration when doing so.

3.8 We support the proposal to allow “any willing/qualified provider” to deliver public health services. In order to make sure that quality is not compromised when multiple providers are competing to deliver services, and to ensure a basic level of uniformity across the country, we would support the development of national frameworks and standardised service specifications for public health services, led by Public Health England.

3.9 These frameworks would set out minimum standards which must be met by organisations when bidding to provide services to achieve the outcomes expected from a quality public health service. A number of guidelines and standards for contraceptive services have already been developed and tested and should provide a starting point for any future work.

3.10 The Committee should consider recommending that Public Health England develops national frameworks for public health services—including for contraceptive and sexual health services—to support the commissioning of effective local services.

3.11 In order to make sure that the new structures of the health service work for both the NHS and public health there are a number of systems which need to be put in place to ensure that NHS commissioning is underpinned by the appropriate public health advice to deliver positive outcomes:

3.11.1Communication—there must be direct channels of communication between Public Health England and the NHS Commissioning Board, as well as between GP commissioning consortia and health and wellbeing boards.

3.11.2Data collection and analysis—collecting standardised, high quality data that can be analysed at national, regional and local levels will allow commissioners to make informed public health commissioning decisions. These data about services and outcomes will be critical to demonstrating the impact of different commissioning decisions on quality, safety and efficacy of patient care. The development and implementation of software support for community sexual and reproductive health services is very tardy. It is not currently possible to compare contraceptive services provided by GPs and Contraception and Sexual Health (CaSH) services, since different data sets are collected and not all of these data sets are made publicly available.

   More meaningful and comparable data on contraceptive services (in all settings) are necessary since they are critical to ensuring integration of care across the NHS and public health and to implement any tariff. Research is needed to establish robust and balanced outcome measures for contraceptive services and data collection systems to measure these. These data will also allow providers to scrutinise their competitors and make decisions about which services they should be delivering and the optimum service delivery model for the locality.

3.11.3Joint Strategic Needs Assessment—local commissioners should be required to undertake an assessment of the sexual health and contraceptive needs of their local population through JSNAs. As the JSNA is developed in partnership between the local authority and GP commissioning consortium (and other partners) this is an extremely useful vehicle to ensure that NHS commissioning is underpinned by public health advice. This must include an understanding of access to contraception across all providers for local women.

4. Structure and Purpose of the Public Health Outcomes Framework

4.1 The AGC supports the establishment of a Public Health Outcomes Framework to sit alongside the NHS Outcomes Framework to support effective co-ordination of responsibility for health outcomes. Whilst 80% of contraceptive services are provided through general practitioners, there is a variety of sexual and reproductive service providers in local communities. It is important that integration of these services, particularly for patients, is encouraged and supported through the Outcomes Framework, and that it is used as a lever to ensure that providers in all settings are delivering consistently high quality sexual and reproductive health services.

4.2 Sexual and reproductive health services contribute to all of the domains in the proposed Public Health Outcomes Framework:

4.2.1Domain 1—Sexual and reproductive health services provide health protection from sexually transmitted infection outbreaks.

4.2.2Domain 2—Unintended, unwanted pregnancy and STIs including HIV can have a long-term impact on life chances and health inequalities.

4.2.3Domain 3—The promotion of good sexual and reproductive health helps to improve wellbeing.

4.2.4Domain 4—Effective sexual and reproductive health services prevent unintended, unwanted pregnancy and ill health.

4.2.5Domain 5—In the most serious cases, sexual and reproductive health services can prevent people from dying prematurely from sexually transmitted infection or reproductive complications.

4.3 We welcome the Public Health White Paper’s commitment towards ensuring a life-course approach to public health and believe this is an important approach when setting out to improve health outcomes for individuals across society. However, we do not believe that all the proposed indicators promote this approach.

4.4 Sexual and reproductive health affects women of all ages and, as such, the AGC believe it is vital that indicators within the Outcomes Framework reflect this in order to ensure they are not skewed to a particular group of people. As a result we advocate the inclusion of an indicator in Domain 3 on unintended, unwanted pregnancy for women of all ages. This would cover both abortion and maternity care.

4.5 Public Health England should also undertake research to identify a balanced set of specific outcome indicators for contraception, in order to ensure none of the indicators selected create a perverse incentive. For example, too strong a focus on the rate of abortion alone as a measure of contraceptive outcomes may lead providers to discourage women from having an abortion, thereby compromising their right to choice.

4.6 The Committee should consider recommending that Public Health England regularly reviews the quality of the indicators selected and carries out research to identify those indicators which will be best suited to deliver on the principles set out in the Public Health White Paper.

4.7 One of the key measures for the success of contraceptive services is whether the people using them feel that they have had a positive experience and felt supported in managing their sexual health needs and exercising their choice.

4.8 That is why the AGC would recommend that PREMs for contraceptive services are used as a proxy for contraceptive outcomes. A standardised questionnaire will need to be established to allow consistent and comparable data to be collected on patient experience of contraceptive services.

4.9 We would ask the Committee to consider recommending that Public Health England looks at the use of PREMs in reporting proxy outcomes for public health services, including sexual and reproductive health services.

5. Future of the Public Health Workforce

5.1 The AGC believes that there is an ongoing need for improved data collection on the sexual and reproductive health workforce. There is currently no audit or register of the number of health professionals qualified to fit each type of LARC. This information is important in allowing commissioners to ensure that they have a sufficient workforce to meet local needs.

5.2 The Committee should consider recommending that information on the number of healthcare professionals trained to fit and remove different types of LARC should be collected by health professionals’ regulatory bodies and reviewed by Public Health England to ensure that there is sufficient provision in all parts of the country.

5.3 We are concerned about the Department of Health’s proposals for the provision of workforce education and training to be made the responsibility of individual providers to fund and organise. There is already a shortage of healthcare professionals trained to provide and fit all forms of contraception, and we are worried that this problem will be exacerbated by the proposed changes to responsibility for training provision. It is imperative that there is a co-ordinated approach to training supported by sufficient funding.

5.4 We believe that there is a need for Public Health England to work with the NHS Commissioning Board to establish national standards of competency for healthcare professionals delivering contraceptive services that would form the basis of requirements for local training provision. These standards will need to take account of the different types of healthcare practitioner delivering contraceptive services. Faculty of sexual and reproductive health already outlines standards for training provision and competency levels.

5.5 For example, the same qualification would not be appropriate for a practice nurse counselling and fitting an intra-uterine contraceptive in a general practice setting and for an abortion surgeon fitting an intra-uterine contraceptive under general anaesthetic. A framework of different levels of competency will therefore be required to take account of different roles.

5.6 The Committee should consider recommending that Public Health England works with relevant stakeholders to establish national standards of competency for healthcare professionals delivering contraceptive services.

5.7 We are concerned that, currently, funding of training is not explicitly included in the activity which will be paid for from the ring-fenced budget. In order to give women a choice of the full range of contraceptive services it is essential that training is provided for all healthcare professionals involved in delivering contraceptive information and care, including on how to fit and remove long-acting reversible contraceptive methods. If training is not going to be funded from within the ring-fenced budget then it is essential that it is made clear where funds will come from to pay for such essential training.

5.8 The Committee should consider recommending that the Department of Health clarifies how workforce training for public health services will be funded within the new structures.

June 2011

APPENDIX 1

The members of the Advisory Group on Contraception are:

Dr Anne Connolly, General Practitioner, The Ridge Medical Practice and Clinical Lead for Women's and Sexual Health, NHS Bradford and Airedale.

Ann Furedi, Chief Executive, bpas.

Baroness Gould of Potternewton, Chair of All Party Parliamentary Group on Sexual and Reproductive Health in the UK, and Co-Chair of the Sexual Health Forum.

Dr Kate Guthrie, Consultant Gynaecologist, Hull Community Healthcare Partnership.

Natika Halil, Director of Information, FPA.

Ruth Lowbury, Chief Executive, Medical Foundation for AIDS and Sexual Health (MedFASH).

Tracy McNeill, International Vice-President and Director of UK and West Europe, Marie Stopes International.

Jennifer Owen, Senior Commissioning Manager, NHS Halton and St Helens.

Jill Shawe, National Association of Nurses for Contraception and Sexual Health.

Dr Connie Smith, Central London Community Healthcare NHS Trust.

Dr Anne Szarewski, Clinical Consultant, Honorary Senior Lecturer, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine and Associate Specialist, Margaret Pyke Centre.

Dr Chris Wilkinson, Lead Consultant, Margaret Pyke Centre.