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Making sense of commissioning

Commissioning in the English National Health Service (NHS) is a multi-faceted process, ranging from health-needs assessment to design of patient pathways, to service specification and to contract negotiation, all with a requirement for continuous quality assessment. The process of commissioning has undergone numerous modifications since it was introduced, with the latest changes brought in by the government’s Health and Social Care Act of 2012. In this issue we publish three separate but related articles on this very current topic.

In his commentary SRH commissioning in England: moving beyond transition, Chris Wilkinson, the President of the Faculty of Sexual & Reproductive Healthcare, draws our attention to the present confused arrangements and uncertainties in the commissioning of sexual and reproductive health (SRH) services, with different groups being responsible for the various aspects of what should be integrated specialties. SRH provision could be one of the key measures of quality in local healthcare programmes, but to achieve this will require urgent changes to the current arrangements. Wilkinson sets out his views on those changes and expresses his determination that the quality of SRH care provided to both women and men must become a more central feature of local health planning. See page 5

As Wilkinson points out, commissioners of services often have insufficient understanding of what should be commissioned, and for whom. ‘Patient and public engagement’ (PPE) is a legal duty for healthcare commissioners, but in A tool to improve patient and public engagement in commissioning sexual and reproductive health and HIV services, Lorenc and Robinson state that there still remains a gap in practical guidance on the methods, processes and standards for PPE in the NHS. They report on the development of SHAPE (Sexual Health And Public Engagement), an online training resource on PPE for commissioners of SRH services, that they hope will help commissioners and others involved in patient care to ensure that patients and the public are genuinely engaged in the development and delivery of sexual health services. See page 8

And in a report from the front line, Ma and Brown’s study, An evaluation of commissioning arrangements for intrauterine and subdermal contraception services from general practitioners in London, UK highlights gross deficiencies and variation in the way that these services were commissioned by Primary Care Trusts (PCTs), the predecessors of the current Clinical Commissioning Groups. Thirty-one PCTs in London were approached to take part in this study. The response rate was poor, as was the data quality provided. Overall, among the responders, there was gross variation between the contracts, poor contract specification and monitoring, and lack of service evaluation. The criteria of the commissioning process were simply not met. Perhaps the commissioning improvements advocated so eloquently by Wilkinson, and the SHAPE training proposed by Lorenc and Robinson, will go some way towards remedying this sorry situation. See page 54

Does NICE always get it right?

Practitioners in the UK and worldwide rely on the authority of guidance issued by the National Institute for Health and Care Excellence (NICE). However, sometimes that guidance may be found to be misleading. In his commentary, Bourne carefully explains why he feels that there are problems with NICE’s 2012 guideline on the diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. It may limit patient choice for management of miscarriage; it is potentially unsafe in relation to the treatment of ectopic pregnancy with methotrexate while ignoring the possibility of expectant management; and certain important clinical problems are not addressed. He concludes that while the guidance contains many sensible suggestions, the evidence should be reviewed and the guideline updated. See page 13

An ethical framework to deal with conflicting health goals

The issue of a possible increase in risk of HIV acquisition with the use of progestogen contraception has been covered previously in this Journal and there are still no definite answers. But what if there were a risk that a highly effective contraceptive method could increase the chances of acquiring serious disease? In their fascinating article, Haddad et al. apply an established framework for managing ethical challenges in public health practice to this difficult problem and conclude that certain contraceptive methods should not be restricted, even if it were proven they could exacerbate the spread of HIV among at-risk individuals. See page 20

The Catholic medical practitioner, family planning, and the Church

In a very personal Viewpoint article, William J LeMaire comments on the dilemma faced by many Catholic practitioners in the field of family planning: should they adhere to the teachings of their church or should they follow their own consciences? Following one’s individual conscience is one of the Catholic church’s teachings, yet such action will often conflict with its opposition to ‘artificial’ methods of family planning. In this context our Organisation Factfile on Catholics for Choice also demonstrates that the church seems to remain out of contact with the opinions of so many of its members. See pages 24 and 74

Introducing MVA in a NHS Sexual Health Service

Despite the known effectiveness and benefits of manual vacuum aspiration (MVA), providers in the UK have tended to offer standard suction termination of pregnancy under general anaesthesia to women who decline or who are too late for medical termination. In this comprehensive article, Pillai et al. report on the introduction of MVA with local anaesthesia into their NHS Sexual Health Service. They found that MVA was very suitable for their outpatient setting and that it was associated with very low levels of pain and bleeding, and an additional benefit was their ability to provide intrauterine contraception at the time of the procedure. The authors’ positive experience should encourage other providers to introduce this option. See page 27

Improving the uptake of emergency contraception: gender does matter

The usual approach to increase the uptake of emergency contraception (EC) and to reduce the number of unintended pregnancies is to target women. But in this study, Schrager et al. challenge the assumption that men play little part in women's use of EC. While both sexes had significant knowledge gaps that could affect EC use rates, the gaps in the young male respondents’ knowledge were, perhaps not surprisingly, significantly greater. Since accurate knowledge about EC and its use is associated with future willingness to use it, the authors suggest that routine visits to healthcare providers could be used as an opportunity to educate men about EC. See page 33

Attitudes towards cervical screening and HPV testing among London Hindu women

In a mixed-methods study, Cadman et al. explored the attitudes, views and understanding of cervical screening and HPV testing among women attending a Hindu temple in London. While screening attendance of this group was only slightly lower than in the general population, familiar barriers to screening were identified. The women felt that they would be able to self-sample for HPV testing, but lacked confidence that samples would be as good as those obtained by clinicians. The findings could be used to inform strategies for increasing uptake of screening in some hard-to-reach groups of women. See page 38

Gay men's experience of surrogacy clinics in India

Following up on their review of research on gay fathers’ reproductive journeys and parenting experiences in the October 2014 Journal, Riggs et al. report on their analysis of interviews with twelve Australian gay men who had entered into surrogacy arrangements in India in order to achieve fatherhood. Not surprisingly they reported both positive and negative experiences, but the most important message that emerged was that they felt that they would benefit from the support of a network of care. This may help to increase the positive outcomes reported by gay men who wish form families through such ‘offshore’ surrogacy. See page 48

A simple strategy for increasing LARC uptake

Can providing information in a simple hand-out increase the uptake of long-acting reversible contraception (LARC)? Trussell and Guthrie introduced an A4 hand-out depicting LARC methods and their effectiveness and looked at the change in the proportion of women choosing LARC. In the family planning service hub, where the reception staff routinely handed out the sheets to the clients, there was a clear impact, achieved in a highly cost-effective manner. But in other locations the sheets were not distributed consistently or at all – and not surprisingly there was no effect. Simple strategies can be very effective, but only if they are actually implemented. See page 60

The 2014 Margaret Jackson Prize Essay

The joint winner of the FSRH’s annual prize for essays by medical students, Ruth Harris, explores the difficult and delicate field of the transition of young people with vertically transmitted HIV infection from paediatric to adult services. This is a very thorough and thoughtful contribution to information on this topic, based partly on Ms Harris's experience of a placement in an adolescent HIV service, and highlights the difficulties in supporting young people with a lifelong disease that can carry stigma for themselves as well as posing risks for others. This essay was a well-deserved prize winner. See page 64

An electronic patient record in a community SRH service

In this article in our Better Way of Working series, Bacon et al. describe the introduction and 5 years of use of an electronic patient record in their community SRH service. They found that systems that had been devised for hospital-based services were unsuitable, but that a system used extensively in general practice was sufficiently flexible to suit their needs, with excellent support systems. Clinic management, results management and audit have been transformed and most staff are happy with the system. The article concludes with useful advice for other services considering making this change. See page 68

Hair today…

Our Consumer Correspondent takes a look the mysteries of pubic hair and concludes that for reasons of health as well as beauty, the tide may be turning for the ‘Brazilian’ and even ‘vajazzling’. See page 72

HIV and contraception - going beyond condoms alone

Historically, the management of people living with HIV has been channelled into improving antiretroviral therapy provision and addressing comorbidities, and there has been little focus on the contraceptive needs of this population. In their large study, Antelman et al. examined the desire for pregnancy and the use of dual contraceptive methods in a sub-Saharan HIV-positive cohort. They highlight the importance of integrating reproductive health services into routine HIV care. Greater discussion of pregnancy desire could lead to safer conception and pregnancy for some, and more effective contraception and reduction of HIV transmission for the majority. See these electronic pages in the online version of the issue.

Improving SRH care for Tanzanian adolescents

Adolescents in Tanzania are denied effective sexual health services, report Dusabe et al. Working with close-to-community providers through focus groups, they identified negative attitudes to adolescents seeking sexual health care. Worrying misconceptions persisted, such as the presence of ‘bugs’ in condoms, or that contraception would prevent later parenthood. Underlying this they describe a lack of resources, sparse training and shortfalls in skills. More positively, they found that these providers (particularly traditional birth attendants, who are popular within communities) are often willing to work together and to engage with the formal health care system. See these electronic pages in the online version of the issue.

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