Commissioning a service for the provision of IUDs and the IUS

Intrauterine devices (IUDs) and the levonorgestrel intrauterine system (LNG-IUS) are forms of long-acting reversible contraception (LARC), which is a contraceptive method that requires administration less that once per cycle or month. NICE clinical guideline CG30 on long-acting reversible contraception identified that all currently available LARC methods are more cost effective than the combined oral contraceptive pill even at 1 year of use. IUDs and the IUS are more cost effective than the injectable contraceptives.

In 2007 the ‘Findings of the baseline review of contraceptive services' reported that 4 million people (most of whom are women) use contraceptive services each year. Around three-quarters of these people see a GP, with the remainder mainly attending specialist community contraceptive services (family planning clinics). However, there is a large variation in GP prescribing for LARC. The full guideline on long-acting reversible contraception noted that the uptake of IUDs and the IUS is low in Great Britain, at around 5% of women aged 16-49 years in 2003/04 compared with 25% for the oral contraceptive pill and 23% for male condoms.

About 30% of pregnancies are unplanned, and the UK has the highest rate of teenage pregnancy in western Europe. The Omnibus Survey Report ‘Contraception and sexual health 2006/07' found that 64% of women interviewed were defined as being ‘at risk' of pregnancy, with those in the 20-34-year age group being at greatest risk. It is anticipated that increasing the uptake of LARC methods, including IUDs and the IUS, will reduce the number of unintended pregnancies, which is a key aim of the government's strategy for sexual health and the teenage pregnancy. The NICE cost impact report for CG30 on long-acting reversible contraception estimated that there are savings to be made from unplanned pregnancies avoided where LARC methods of contraception are used.

The LNG-IUS is a long-term progestogen-only method of contraception that is a first-line option for the management of heavy menstrual bleeding (HMB). HMB, also known as menorrhagia, affects around one in three women^[1]. It is defined as excessive menstrual blood loss that interferes with the physical, emotional, social and material quality of a woman's life. Many women with HMB consult healthcare professionals in primary care and HMB is a common reason for referral to a specialist. Optimal pharmaceutical management improves choice and provides an alternative to surgery, thus reducing referral rates to secondary care^[2].

Benefits

The potential benefits of robustly commissioning services that effectively provide IUDs and the IUS for LARC, and the IUS for the care of women with HMB, and providing better care for women requiring contraception or with HMB include:

• Reducing the numbers of unintended pregnancy, contributing to the Public Sector Agreement target to halve the number of under-18 conception rates by 50% by 2010 as part of a broader strategy to improve sexual health. LARC methods are highly effective because they are not dependent on daily concordance and have lower failure rates (0.05% to 2%) than the combined pill and minipill (8%)^[3].
• Reducing the number of avoidable referrals to acute hospital based gynaecology services by improving access to IUDs and the IUS.
• Reducing the number of hysterectomies performed and the cost of HMB to health services by optimising the pharmaceutical management of HMB and offering less invasive treatment. See also the commissioning guides on hysterectomy and endometrial ablation.
• Providing patient-centred and effective clinical care of women with HMB by optimising pharmaceutical management as recommended in NICE clinical guideline CG44 on heavy menstrual bleeding.
• Reducing inequalities and improving patient access to services.
• Increasing patient choice and patient engagement in decision-making about options for contraception and the management of HMB, both of which should contribute to improving patient experience.
• Better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways. LARC methods are more cost effective than the combined oral contraceptive pill even at 1 year of use, and they prevent more unplanned pregnancies than the pill. The NICE cost impact report for CG30 on long-acting reversible contraception estimated that a PCT with a population of 40,000 women aged 15-49 years could save more than £300,000 by implementing the NICE clinical guideline CG30 on long-acting reversible contraception.

Key clinical issues

Key clinical issues for commissioning a service for the provision of IUDs and the IUS are:

• Accurately identifying women suitable for LARC
• Accurately identifying and diagnosing women with HMB to support clinically appropriate care and optimal pharmaceutical management. Access to ultrasound scan and endometrial assessment (biopsy and hysteroscopy) for the diagnosis of HMB, and microbiology services for the provision of testing for sexually transmitted infections, where appropriate, is required.
• Ensuring that appropriate referral pathways are in place to support access to IUDs and the IUS from service providers who do not offer LARC, for emergency contraception and for the management of HMB.

National priorities

National priorities and initiatives relevant to commissioning a service for the provision of IUDs and IUS include:

• World class commissioning.
• The NHS in England: The operating framework for 2009/10.
• National service framework for children, young people and maternity services: core standards.
• Delivering the 18 week patient treatment and the heavy menstrual bleeding pathway pathway.
• Every child matters.
• Choosing Health: making healthy choices easier.
• The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Commissioning framework for health and well-being.
• Considering the impact of patient choice.
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with ‘Standards for better health'.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. Kennedy ADM, Sculpher MJ, Coulter A et al. (2003) A multicentre randomised controlled trial assessing the costs and benefits of using structured information and analysis of women's preferences in the management of menorrhagia. Health Technology Assessment 7(8).

2. Grant C, Gallier L, Fahey T et al. (2000) Management of menhorrhagia in primary care - impact on referral and hysterectomy: data from the Somerset Morbidity Project. Journal of Epidemiology and Community Health 54: 709-13.

3. National Institute for Health and Clinical Excellence (2007) Long-acting reversible contraception: Full guideline 30. London: National Institute for Health and Clinical Excellence.