Increasing the Proportion of Women using Long Acting Reversible Contraception (LARC) within a Geographical Area in Scotland Dr Audrey Brown

Greater Glasgow and Clyde

Long-acting reversible contraception National Institute for Clinical Health and Excellence (NICE) 2005 –Women should be offered a choice of all methods including LARC. –All LARC methods are more cost effective than the combined oral contraceptive pill even at 1 year of use. –IUDs, IUS and implants are more cost effective than the injectable contraceptives. –Increasing the use of LARC will reduce unwanted pregnancies

Scotland 2004/5 Uptake intra-uterine device, intra-uterine system, contraceptive implant per 1000 women aged Rate per 1000 women within Scotland Rate per 1000 women within GGC 2317

GGC – time for action Target set to increase from 17/1000 to 85/1000 in 5 years

National Drivers Key Clinical Indicator (KCI) on LARC – Information and Statistics Division – annual reporting of uptake by board area Quality Improvement Scotland (QIS) – standard on intrauterine and implantable methods of contraception National LARC awareness campaign

Key Clinical Indicators for Sexual Health: Population Based Indicator Termination of Pregnancy Sterilisation Long Acting Reversible Contraception Chlamydia HIV Therapy

QIS LARC standard Essential Criteria Women requiring contraception are given information about, and offered a choice of, all methods of contraception including intra-uterine and implantable contraceptives 60 or more females per 1000 of reproductive age per year are prescribed intrauterine and implantable contraceptives Contraceptive providers who do not provide intrauterine and implantable contraceptives have an agreed mechanism in place for referring women A consultation appointment with a service providing intrauterine and implantable contraceptives is available within 5 working days Desirable criterion 100 or more females per 1000 of reproductive age per year are prescribed intrauterine and implantable contraceptives by the end of 2011

Media launch Retail outlets Cinemas Gym changing rooms Bar toilets

Local action: Raise awareness through distribution of LARC resource pack Contraceptive prescribing guidance for primary care Improve access to free training, especially for nursing staff, both primary care and acutes Reimburse primary care practitioners for provision of LARC in general practice Locality mapping to drive local planning Improve access to LARC at Sandyford

LARC Resource Pack This resource pack is designed to support both CHPs and specialist sexual health services in planning developments and implementation of local LARC (Long Acting Reversible Contraception) services. Section 1 – National LARC Policy & Perspective Major documents supporting the rationale of increasing the use of LARC methods will reduce rates of unintended pregnancy in a cost effective manner Comparative rates of effectiveness of different contraceptive methods Section 2 – An Overview of LARC Usage Levels at National, Board & CHP Level An overview of LARC usage for the national board-wide and CHP perspective including local mapping reports. Section 3 – LARC Protocols & Guidance Documents Protocols and Clinical Guidance documents supporting provision of LARC GP Contraceptive Prescribing Guidance Faculty of Sexual & Reproductive Healthcare Guidance on LARC Section 4 – GP Income & Local Payments QOF Agreement for LARC 2009/10 Enhanced Service Agreements Section 5A – LARC Training Faculty of Sexual & Reproductive Healthcare training package CDs for fitting Implants, IUD/IUS and EHC provisionn Faculty Information re obtainment of Letters of Competence Nurse training documentation – RCN & West MCN Guidance, PGDs Information on how to access training locally through Sandyford Section 5B – LARC Education Useful websites & online resources Available meetings & courses Resources available refer to sections 6 & 7 Section 6 – LARC Patient Perspective Patient/Client perspective 2 Articles from Peer Review Journals (article D Mansour et all European Journal of Contraception ) RAGS article WISH Report National Sexual Health Awareness Campaign materials Section 7 – Patient Resources for LARC Patient/Client Information Information on how to access written leaflets and posters locally Useful websites Examples of patient information leaflets (FPA, Health Scotland ) Sandyford materials for signposting/referring patients to local services. Section 8 – Templates & Tools for Local LARC Planning, Audit & Implementation. This section contains some examples of templates that can be adapted and supported at a local CHP level. Some examples have been included: Needs Assessment Audits Implementation/Action Plans

CONTRACEPTIVE PRESCRIBING IN PRIMARY CARE Patient requests contraception  Take full medical and sexual history  Check BP and smear status  Offer STI screening  Discuss contraceptive choices taking into account the above and patient preference Consider long-acting reversible contraception (LARC) as first line option as this is the most effective way to avoid pregnancy LONG-ACTING REVERSIBLE CONTRACEPTION (LARC) See Nice CG30 (Long-acting Reversible Contraception – Oct 2005)  Progesterone-only implant ( Implanon ® ) - Lasts 3 years  Copper IUD ( TT380 Slimline ® ) - Lasts 10 years  Progestogen-only IUS ( Mirena ® ) - Lasts 5 years Useful if menorrhagia present  Progestogen-only depot ( Depo-Provera ® ) Given every 12 weeks  NB: The effectiveness of LARC preparations containing hormones, such as Implanon ® may be affected by interacting medicines. Refer to individual SPC or BNF for guidance Consider appropriateness of COC or POP taking into account patients age, medical history, risk factors and patient preferences COC appropriatePOP appropriate Micronor ® or Femulen ® Should be considered 1 st line POPs  Cerazette ® should only be considered in women who cannot tolerate or have contraindications to oestrogen containing contraceptives  Cerazette ® may also have advantages in women with a history of poor compliance  1 st line choice should be a standard strength 2 nd generation such as Microgynon 30 ® or Loestrin 30 ®  If patient suffers from acne, consider Marvelon ® Adverse effects, poor cycle control or poor compliance may dictate further options

Local Enhanced Service National Enhanced Service Contraceptive Implant In each practice contracted to provide the contraceptive implant service will receive a £25.81 insertion fee and £51.61 removal fee per patient IUD/IUS In each practice contracted to provide the IUD/IUS service will receive a £79.92 insertion fee per patient.

Capturing termination of pregnancy population Over 3000 TOPs annually in GGC Over 1 in 4 are repeat TOP Two thirds performed medically Local training programme for gynaecology nurses to train in implant insertion

GGC women undergoing MTOP in 2007 and 2010

GGC women undergoing MTOP in 2007 and 2010

MTOP and STOP women

Improving access to LARC at Sandyford Redesign of Sandyford Central drop-in services Sept 2009 Increase drop-in registration hours from 2 hour window to 5 hour window Offer LARC fitting at drop-in

IUD/IUS insertion or reinsertion –Jan - Aug –Sept 09 – Feb10 152

Implant insertion or reinsertion –Jan – Aug –Sept 09 – Feb

Activity in 2004/05 vs 2009/10 in GGC 1° Care2°CareTotal Impl IUD/ IUS vLARC ° Care2°CareTotal Impl IUD/ IUS vLARC

5 years on….. Rate per 1000 women within Scotland Rate per 1000 women within GGC 2004/ / / / / /105769

Summary Uptake of LARC in GGC has increased from 17/1000 women to 69/1000 women over 5 years Increase in uptake in GGC has outperformed that in Scotland as a whole A combination of national and local drivers are likely to have contributed We did not meet our own target of a 5 fold increase in uptake in 5 years But we did meet the essential QIS target of 60 per 1000 women being prescribed LARC