Discussion

From the 48% response rate we can confidently say that almost half the PCTs in London commissioned IUC and/or SDI services from their GPs. If non-responders were from PCTs without such contracts, this would suggest that women living in some parts of London had no access to some methods of LARC from their GPs, which meant that local contraceptive and sexual health services might be the sole providers, creating potential problems with capacity and access.

Some general practices might have been commissioned by their PCTs to extend their services to patients registered with other practices in the area; this already happens in the case of minor surgery where a ‘host practice’ provides services under the Directed Enhanced Service (DES) arrangement for patients belonging to other practices. It was not possible to tell from this study if similar arrangements were in place for IUC and SDI services. This way of commissioning LARC could be considered to help improve access in addition to services from CASH providers as not every GP practice provides IUC or SDI services.

We were not able to obtain all the required information from all the PCTs in the sampling timeframe. At that time (Quarters 3 and 4 of the financial year 2011/2012) PCTs were undergoing transition due to NHS reforms; many members of commissioning teams were either no longer in post or had moved to different departments. This might have contributed to the low response rate and difficulties in obtaining the required information such as activity data.

We were disappointed that PCTs were not able to give us accurate activity information under each contract. Contract monitoring and evaluation are part of the commissioning cycle so we expected a system of recording how much individual practices were paid for their performance.12 It was difficult to locate key members of PCT staff to obtain the activity data; commissioning departments that managed the contracts for GPs were often different to the departments that processed the activity returns from practices and managed the payments. This also meant the commissioners did not always have the activity data to monitor performance against the contracts. Commissioners should have access to activity data so that they can monitor the performance of providers; it may, however, be a matter of financial probity for another department to manage the payments.

We found that some PCTs used a model of commissioning arrangement whereby STI and contraception were ‘bundled’ together into a single contract. One PCT provided a rationale for this in the contract specification, in the objective to provide a broader remit of sexual health care from their GPs (which included STI testing and treatment in addition to providing LARC). We support this approach as quite often testing and management of STIs/HIV have been separated from contraception provision; having a ‘bundled’ contract helps promote holistic sexual health care.

We sought to explain the variation in payment for IUC/SDI fitting and removals. It would seem reasonable for payments to reflect the cost of providing the service, for example, the doctor's and assistant's time, fitting/removal equipment, overhead costs as well as the cost of the device itself. According to the British National Formulary September 2013 edition, the typical cost of devices ranged from £8.95 for the Copper T 380A^® IUD to £88.00 for the Mirena^® IUS and £79.46 for the Nexplanon^® contraceptive implant.13 GPs are reimbursed separately for IUDs or IUS through the drugs reimbursement system so these costs are not incurred by them. One PCT included the rationale for higher payment for contraceptive implants in the service specification as they are not reimbursed in the same way as IUC, so this was reflected to recoup the cost of implants in the service payment. We had difficulty justifying a tariff of £80.00 for an IUC removal.

In some PCTs, because there was no local specification for contraceptive implant insertion and removal, some commissioners used an established service specification such as Minor Surgery DES to pay GPs for these procedures. One PCT contract specification mentioned “implant insertion is classified as minor surgery” and reimbursed £43.00 and £33.00 for insertion and removal, respectively. Minor Surgery DES has two levels of payment: procedures to remove benign ‘lumps and bumps’ that require cutting and another for joint injections. The reimbursements were £80.00 and £40.00, respectively, at 2003/2004 prices.14 Given these points, we did not feel a tariff of £30.00 fairly reflected the complexity of contraceptive implant removal compared with insertion, especially with the cost of staff time and equipment involved.

The results of this evaluation also showed variation in clinical governance, which may have implications for clinical safety. Two contracts did not stipulate the minimum level of competence required by the health care professional who is commissioned to provide the service. While it was reassuring to see clinical governance issues for safe delivery of services such as practitioner competence, infection control and resuscitation facilities stipulated in many of the contracts, we feel these are essential and should be made explicit in every contract.

Litigation can occur in connection with IUC fittings, and medical defence organisations have warned doctors about the need for good clinical assessment, maintaining competence and adequate note-keeping.15 Both the NICE guidance and FSRH guidance on reaccreditation of IUC fitting stipulate a minimal level of activity to maintain competence.3 ,10 They also encourage annual audits to enable practitioners to reflect on the standard of care delivered.

Recent NHS reforms in line with the Health and Social Care Act 2012 have created new commissioning arrangements for services such as STI testing and LARC.16 ,17 These services will be commissioned by local authorities from a range of providers such as general practices and ‘any qualified providers’ such as third-sector and other non-NHS providers. Local authority commissioners may not have experience in commissioning clinical services compared with the PCTs they have replaced. We hope our study will help inform local commissioning arrangements for some aspects of reproductive health, and remind commissioners that it is imperative to have robust clinical and financial governance systems in place.

Local authorities will also need to negotiate with providers a reasonable reimbursement for provision of intrauterine and subdermal contraception. We hope this evaluation will provide a point of reference for local contract negotiations. Because of the need for local negotiations we do not have a ‘model’ contract to recommend. Guidelines for clinical safety and governance aspects are already available from sources such as NICE and the FSRH.

Some GP LARC champions were involved to varying degrees in designing these contracts and monitoring activities from practices in their local PCTs. We strongly suggest that future commissioners seek advice from experienced clinicians such as LARC champions, suitably qualified GPs or lead clinicians in CASH services to design the contracts and to be involved in managing the clinical governance. This will ensure that all providers are working to high standards and adhering to current best practice.