Select Committee on Health Minutes of Evidence


Memorandum by Dr Sarah Randall (SH 93)

CONTRACEPTION SERVICES—WHAT ARE THE ISSUES?

  All women should have equitable access to all methods of contraception, provided by appropriately trained staff in acceptable settings. This is not the reality.

BACKGROUND

  The current provision of service is a legacy from 1974 when the voluntary sector Family Planning Association [fpa] clinics were subsumed into the NHS. From then on contraception was provided by both general practitioners and the NHS community clinics. Over the last 15-20 years the provision by general practice has increased to approximately 80 per cent compared to 20 per cent in the community clinics. However, the specialists remained within the community, so that the ratio of simple contraception [eg contraceptive pills] to specialist methods [eg coils and implants] is heavily weighted to the community services.

  Funding for the services is different, with GPs currently receiving item of service payments dependent on method, whereas clinic staff receive a standard salary to cover all services. Clinic funding has to date usually come from Health Care Trust budgets, but from now on will be funded by Primary Care Trusts, except for a small number of units who have moved into an Acute Hospital Trust.

  Community clinics are an important resource of specialist knowledge. They have continued to provide the specialists in this area, whereas the GPs have tended to remain the generalists. This means that community clinics are at present often the only providers of services and training at level 2 and 3.

  Community clinics also provide level 1 services for many clients: those not registered with a GP or whose GP does not provide contraceptive services, those who for personal and cultural reasons do not want to go to their own GP and those who cannot get an appointment with their GP. Most community clinics offer open access—they see clients from any geographical area and usually offer a high proportion of non-appointment, drop-in sessions at which any contraceptive method can be discussed and usually provided.

  There are a few community clinics where there is a lack of appropriate leadership [usually because of financial problems] and in these situations service provision is not what it could be.

WORKFORCE

  There are 218 community service providers within the UK [171 in England and 14 Brook Clinics], with 74 consultants and 90 lead Senior Clinical Medical Officers or Associate Specialists with a whole time equivalent of 100. One thousand eight hundred and fifty three other staff are employed, mainly part time with a wte of only 268. Services provide not only contraception but also psychosexual counselling, menopause care, domiciliary services for vulnerable groups and termination counselling and more often termination operations. Many centres undertake research and the majority of training takes place in these community clinics. Clinics provide sex education in schools and educational programmes for non health personnel.

TRAINING

  Basic training in contraception is included in the GPs three year vocational training course. The Faculty of Family Planning and Reproductive Health Care [FFPRHC] organises theoretical and practical training leading to a Diploma in basic contraception care. In many areas, GP registrars are encouraged to take this course. Acquisition of the DFFP is mandatory in all community clinics but not in general practice.

  Specialist training in coils and implants is also provided by the Faculty. Whereas it is again mandatory for doctors offering these methods in community clinics, it is not a requirement within general practice, although advised. Re-accreditation of the Diploma and Letters of Competence in coils and implants is a requirement of community work.

  The Faculty is working with the Royal College of General Practitioners with regards to ongoing training within general practice and has also been liaising with the Medical Society for Venereal Diseases [MSSVD], so that the new Diploma includes a significant element of sexually transmitted infection training.

  The career pathways for doctors entering GUM or general practice are clear. This has not been and is still not the case for those wanting to specialise in contraception and sexual health. Due to European law, contraception and reproductive health, with all its complexities, is not recognised in this country as a separate speciality as is GUM. Therefore the only access to consultant posts is via training in obstetrics and gynaecology [O&G]. The reduction in training numbers in O&G and lack of funding has meant that only 11 centres are approved for training and to date only 10 specialists have been accredited and can take up consultant vacancies. Some doctors who do not want to follow the obstetric and gynaecology route have done public health medicine training and five trainees should become eligible for consultant posts having trained via this route. The Faculty is acutely aware of the need for more specialists. There are 25 predicted retirements of senior doctors [consultants] in the next two years. To address this problem, the Faculty has set up its own three year training programme leading to a specialist qualification.

ISSUES FOR CONSIDERATION
IssueImpact
Many areas have seen their clinics cut as Health Care Trusts sought to save money, despite the fact that two studies have shown contraceptive community clinics to be very cost effective. 30 per cent community clinics are open "out of hours". Cuts in services mean loss of client choice.

Whereas many GUM clinics have longer waiting times as their appointments are over booked, staff working in non-appointment FP clinics find themselves working longer sessions in order to meet the increasing demand.

It is not unusual for us to see over 70 clients in an evening session.
Sexual Health Strategy.This may increase the workload of community clinics if more STI work is absorbed. This will be unsustainable.
Trusts and PCTs could choose to limit funding for new contraceptive methods ie implants. GPs can prescribe these methods, but often do not have the expertise to fit them. Clinics have the expertise, but no funding for the devices. Regulations on whether GPs can prescribe for others to fit have been confusing and led to many problems.
PCTs may choose to ignore community clinics, thinking that they are an unnecessary duplication to GP provision. At present, most GP services are not in a position to take over all three services currently provided by community clinics. Even if they could, many areas have unfilled GP posts.
Many community clinics have been requested to only see clients under age 25. Community clinics provide the basic training for both GPs and practice nurses. Clinics cannot train effectively if they do not see the full range of clients.
Disparity exists between what a clinic doctor is paid for a three hour session [£68] and what a GP would receive [£130]. This results in difficulty in recruiting/retaining staff.
Some clients choose to access community clinics because they wish to be seen by a female doctor. Although there are now many more females working within general practice, a surgery cannot always guarantee a client will see a female member of staff.
Training issues.Family planning needs to be recognised as a speciality in its own right. Then the Faculty's training programme could possibly be recognised and doctors become eligible for consultant posts.
Standards of training and hence care need to be equitable in community and primary care settings. Clients need to be made aware of the competencies of the provider. Community specialists will require time and funding to equip primary care for its new role in the Sexual Health Strategy.
If some GP practices or clinics are not going to offer a full range of methods, this needs to be made clear to the client. Robust open advertising is essential and is not occurring at present.
Data is collected on community service provision, but data from general practice is rudimentary. A combined data set is required.

THE WAY FORWARD

  Impending consultant [senior staff] shortages need to be addressed.

  Specialist training needs to be addressed.

  Basic training requirements for primary care and community clinics need to be agreed.

  Joint standards on such issues as confidentiality, access and provision need to be established.

  The Commissioning Tool Kit is frequently mentioned in the SHS and will be vital to the provision of future services. There needs to be full collaboration with the organisations involved in SH to ensure standardised services for future.

  The new GP contract suggests the FP will be included as "additional" services, but details on training or standards are unclear. We cannot know what impact this new contract will have on current service provision. It is possible that GPs may undertake less specialist work, which could result in a major impact on community clinics.

  Community doctors have long demonstrated partnership with primary care to ensure and improve quality of service. We need to build on this, acknowledging the strengths that both have and by sharing our expertise.


 
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Prepared 19 August 2002