Ensuring corporate and quality assurance

Commissioners should ensure that the services they commission represent value for money and offer the best possible outcomes for patients. Commissioners need to set clear specifications for monitoring and assuring quality in the service contract.

Commissioners should ensure that they consider both the clinical and economic viability of the service, and any related services, and take into account patients' views and those of other stakeholders when making commissioning decisions.

A service providing intrauterine devices (IUDs) and the intrauterine system (IUS) needs to:

• be effective and efficient - commissioners should consider one stop assessment and treatment where appropriate
• be responsive to the needs of patients, and support patient choice of all methods of contraception and their access to clinically appropriate treatment for heavy menstrual bleeding (HMB)
• provide treatment and care based on best practice as defined in NICE clinical guideline CG30 on long-acting reversible contraception, NICE clinical guideline CG44 on heavy menstrual bleeding and NICE public health guidance PHI003 on preventing sexually transmitted infections and reducing under-18 conceptions
• deliver the required capacity
• be integrated with other elements of contraceptive services and care for women with HMB
• define agreed criteria for referral, local protocols and the care pathway for women with HMB
• be patient-centred and provide equitable access, ensuring that patients are treated with dignity and respect, are fully informed about their care and are able to make decisions about their care in partnership with healthcare professionals
• audit uptake of long-acting reversible contraception, including IUDs and the IUS, and pharmaceutical treatments for the management of HMB to ensure clinically appropriate care
• demonstrate how it meets requirements under equalities legislation
• demonstrate value for money.

Local quality assurance

Any mechanisms for quality assurance at a local level are likely to refer to the following.

• Service and performance targets, including estimated activity levels and case mix, waiting and referral-to-treatment times (ensuring that patients do not experience unnecessary delays), complaints procedures. Commissioners may wish to consider developing key performance indicators within contractual arrangements in line with the guidance in ‘Care and resource utilisation: ensuring appropriateness of care'. This could be, for example, by developing integrated care pathways and thresholds for treatment with clinicians, and seeking to manage levels of activity to an agreed local level for some procedures.
• Clinical governance arrangements, including incident reporting. Commissioners and contraceptive providers should be aware that the risk of perforation is related to the skill of the healthcare professional inserting the IUD or IUS. Policies and procedures should be considered for the management of potentially difficult fittings and removals, complications, uterine perforation, and for the treatment of people with epilepsy during insertion of an IUD or the IUS.
• Clinical quality criteria: appropriateness of referral, consenting procedures, clinical protocols including referral where healthcare professionals do not provide LARC within their own practice.
• Audit arrangements: frequency of reporting, reporting route and format, and dissemination mechanisms. See audit criteria in appendix D of NICE clinical guideline CG30 on long-acting reversible contraception and audit criteria for NICE clinical guideline CG44 on heavy menstrual bleeding.
• Health, safety and security: infection control, waste management, confidentiality procedures, legislative requirements.
• Equipment: including decontamination requirements.
• Accreditation requirements: for some or all elements of the service, the premises and/or staff. Healthcare professionals undertaking the insertion of IUDs and IUS should have appropriate training. This should be based on modern, authoritative medical opinion.
• Patient satisfaction: patient perspective and perception of service provision, complaints.
• Patient outcomes: increased uptake of LARC methods of contraception, removal of IUDs and the IUS within 1 year of fitting, numbers of unintended pregnancy, optimising pharmaceutical management of HMB, and hysterectomy rates
• Staff competencies: individual and team baseline requirements, monitoring and performance. NICE clinical guideline CG30 on LARC recommends that IUDs and the IUS should only be fitted by trained personnel with continuing experience of inserting at least one IUD or one IUS a month. The need for appropriate training and regular continuing professional development should be considered and monitored. The topic-specific advisory group recommends that service providers should also be able to provide local anaesthesia and pain management during IUD and IUS fittings.
• Information requirements, including both patient-specific information (NHS number, referring GP, provision of high-quality information to patients/carers) and service-specific information (referral trends by healthcare professionals who do not provide LARC within their own practice/service, number of complaints). The ‘Findings of the baseline review of contraceptive services' recommends that commissioners monitor the usage of LARC methods of contraception. However, current availability of data within specialist community contraceptive services is variable, and may not identify if the use of IUDs and the IUS is for contraception or management of HMB. KT31 data collection is currently being amended to include PCT wide data. Commissioners may wish to monitor clinical indicators i.e. the number of IUDs and IUS fittings being carried out in secondary care, endometrial ablation, hysterectomy and sterilisation rates.
• The process for reviewing the service with stakeholders, including decisions on changes necessary to improve or to decommission the service.
• Achieving targets associated with equalities legislation.

Further information

General information on quality and corporate assurance can be obtained from the following sources:

• ‘Implementing care closer to home: Convenient quality care for patients part 3: accreditation of GPs and pharmacists with special interests'.
• Department of Health and Royal College of Nursing publication ‘Freedom to practice: dispelling myths'.
• The National Patient Safety Agency (NPSA) oversees the implementation of a system to report and learn from adverse events and near misses occurring in the NHS. The publication ‘Seven steps to patient safety' provides an overview of patient safety and gives updates on the tools that the NPSA is developing to support patient safety across the health service.
• NHS Alliance online resources. NHS Alliance is the representational organisation of primary care and primary care trusts, and provides them with an opportunity to network and exchange best practice. The alliance supports its members with an open-access helpline, in-house and joint publications and briefings, internal newsletters and a website.
• The DH commissioning framework provides guidance on the commissioning process in the context of the NHS reform agenda.
• ‘Delivering the 18 week patient pathway' provides a range of resources to support the key NHS objective to deliver an 18 week patient pathway from GP referral to the start of treatment by the end of 2008, and the heavy menstrual bleeding pathway.
• NHS Institute for Innovation and Improvement support for commissioners, includes Commissioning for Health Improvement products to accelerate the achievement of world class commissioning; The Productive Leader programme to enable leadership teams to reduce waste and variation in personal work processes, and Better care, better value indicators to help inform planning, to inform views on the scale of potential efficiency savings in different aspects of care, and to generate ideas on how to achieve these savings
• ‘10 Steps to your SES: a guide to developing a single equality scheme'. This guidance has been developed to assist NHS organisations that have a duty, as public authorities, to comply with the race, disability and gender public sector duties, and in anticipation of new duties in relation to age, religion and belief, and sexual orientation.

Specific information on quality and corporate assurance for a service for IUDs and the IUS can be obtained from the following sources:

• Specification for the national enhanced service for IUDs
• Faculty of Family, Sexual and Reproductive Healthcare offers training, competence assessment in intrauterine techniques, service standards, guidance on good medical practice and clinical governance arrangements.
• The Royal College of Nursing (RCN) offers the following guidance: ‘Contraception and sexual health in primary care: guidance for nursing staff' and ‘Fitting intrauterine devices: RCN training guidance for nurses and midwives'.
• Better metrics is a pragmatic project that provides clinically relevant measures of performance to support the development of measurable local targets and indicators for local quality improvement projects. See improving the patient experience metric number 11 relating to adult inpatient and outpatient experience.
• ‘Skills for health' works with employers and other stakeholders to ensure that those working in the sector are equipped with the right skills to support the development and delivery of healthcare services. See details of the clinical health skills competency framework.