Specifying a service for the provision of IUDs and the IUS

Service components

The key components of services providing intrauterine devices (IUDs) and the intrauterine system (IUS) are:

• ensuring appropriate choice of contraception and subsequent access to a service providing IUDs and the IUS
• ensuring appropriate assessment and care of women with heavy menstrual bleeding (HMB)
• developing a high-quality service providing IUDs and the IUS.

Ensuring appropriate choice of contraception and subsequent access to a service providing IUDs and the IUS

Enabling women to make an informed choice and addressing women's preferences is important. The NICE clinical guideline CG30 on long-acting reversible contraception recommends that:

• Women requiring contraception should be given information (both verbal and written) about different methods of contraception, including IUDs and the IUS methods, that will enable them to choose a method and use it effectively. See ‘Understanding NICE guidance'.
• Healthcare professionals advising women about contraceptive choices should be competent to:
  - help women to consider and compare the risks and benefits of all methods relevant to their individual needs
  - manage common side effects and problems.
• Counselling about contraception should be sensitive to cultural differences and religious beliefs.
• Women with learning and/or physical disabilities should be supported in making their own decisions about contraception.

The NICE cost impact report for CG30 on long-acting reversible contraception states that women currently using contraceptive methods other than LARC or the contraceptive pill who are given better information and access to services may wish to choose a LARC method. The current limited use of LARC suggests that healthcare professionals may need better guidance and training so that they can help women make an informed choice. Addressing this will take time and planning, and commissioners may wish to ensure that the skills and knowledge of all LARC methods are increased within primary care.

Commissioners also need to consider having agreed mechanisms in place for referring women, for whom IUDs and the IUS are suitable and chosen options, from provider services that do not offer LARC.

Appropriate care and onward referral for women with HMB

The use of levonorgestrel-releasing IUS (LNG-IUS) is a first-line treatment option for women with HMB. The diagnosis and general management of HMB is described in detail in NICE clinical guideline CG44 on heavy menstrual bleeding. It is clearly important to identify women suitable to use the IUS to ensure delivery of care based on the best available evidence. The clinical guideline recommends:

• LNG-IUS should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity
• the healthcare professional should determine whether hormonal contraception is acceptable to the woman before recommending treatment (for example, she may wish to conceive).

Commissioners need to be aware that examinations and investigations for HMB to determine the suitability of LNG-IUS as a treatment option may be required. These may include physical examination, ultrasound (first-line diagnostic tool for identifying structural abnormalities), biopsy and hysteroscopy as outlined in the NICE clinical guideline CG44 on heavy menstrual bleeding. Their provision will need to be considered in local integrated care pathways.

See also the commissioning guides on hysterectomy and endometrial ablation.

Developing a high-quality service providing IUDs and the IUS

Commissioners should be aware that having appropriately trained staff and arrangements for managing sexually transmitted infections (STI) is of key importance.

NICE clinical guideline CG30 on long-acting reversible contraception recommends that:

• healthcare professionals providing intrauterine or subdermal contraceptives should receive training to develop and maintain the relevant skills to provide LARC methods of contraception
• 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
• healthcare professionals helping women to make contraceptive choices should be familiar with nationally agreed guidance on medical eligibility and recommendations for contraceptive use.

Treatment, care and information should be culturally appropriate and in a form that is accessible to people who have additional needs.

Because the risk of uterine perforation is related to the skill of the healthcare professional inserting the IUD or IUS, commissioners will wish to assure themselves that healthcare professionals, both existing and newly involved in this service provision, are competent. Community contraceptive services are reported by the ‘Findings of the baseline review of contraceptive services' to be the main providers of training to general practice. The topic-specific advisory group noted that where patient counselling is poor and patients do not have adequate time to reflect before the fitting, removal rates of IUDs and the IUS within the first year of fitting may be high. This could be used as an indicator of service quality.

NICE public health guidance PHI003 on preventing sexually transmitted infections and reducing under-18 conceptions' recommends that commissioners should:

• Ensure that sexual health services, including contraceptive and abortion services, are in place to meet local needs. All services should include arrangements for the notification, testing, treatment and follow-up of partners of people who have a sexually transmitted infection (partner notification).
• Ensure staff are appropriately trained, and that an audit and monitoring framework is in place.

Commissioners may wish to consider which of the various service models to provide IUDs and the IUS are the most appropriate for their locality, and mixed models of provision may be appropriate across a local health economy. They may also need to consider arrangements for difficult fittings and removals, and the provision of information and choice of all methods of contraception, including IUDs and the IUS, within the follow-up care provided by termination of pregnancy services.

Examples of service models are given in the report ‘Shifting care closer to home: care closer to home demonstration site - report of the speciality subgroups'.The report identifies innovative ways of delivering gynaecology and contraceptive services. These include: primary care led models of integrated care provided by GPwSIs, community contraceptive services, GP enhanced services and nurse led models of provision. The use of integrated care pathways for HMB have been shown to reduce outpatient attendance while improving patient experience and maintaining quality of care^[1][2]. The examples are offered to share local practice, but NICE makes no judgement on the compliance of these services with its guidance.

The national enhanced service for IUDs sets out the requirements for the provision of IUDs within primary care. The specification notes that special equipment is required. This includes an appropriate room fitted with a couch and with adequate space and equipment for resuscitation, equipment for cervical anaesthesia and a variety of vaginal specula and cervical dilators. In addition, an appropriately trained nurse needs to be present to support the patient and assist the doctor during the procedure. NICE clinical guideline CG30 on long-acting reversible contraception also recommends that anti-epileptic medication should be available at the time of IUD or IUS insertion in a woman with epilepsy.

Local stakeholders, including service users, should be involved in determining what is needed from a service providing IUDs and the IUS in order to meet local needs. The service should be patient-centred, meeting the needs of the local population (including those at risk of unintended pregnancy), and be integrated with other elements of contraceptive care and care for women with HMB. Commissioners may wish to audit current provision, local GP referral rates, uptake of LARC methods and where patients are attending for fittings and removals. This will provide them with the opportunity to review current practice and to develop an integrated care pathway with clinicians to provide assessment and treatment for people requiring contraception or with HMB at a single visit where appropriate. As the management of HMB shifts from secondary to primary care, commissioners will need to engage local clinicians in agreeing treatment thresholds for intervention and develop strategies for how to manage the care of more women in general practice or community contraceptive services.

The service specification needs to consider:

• the required competencies of, and training for, existing and new staff responsible for providing the service
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access and service location including direct access, self referral and out-of-hours provision; commissioners should engage with service users and other relevant individuals and organisations locally
• care and referral pathways for contraceptive service providers who do not offer LARC methods to support choice and access to appropriate care
• information and audit requirements, including IT support and infrastructure to monitor offer of choice and take up of LARC methods of contraception and treatment for HMB
• planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway for HMB or equitable waiting times locally for those services currently outside 18 weeks. See ‘Choice of scan: guidance'
• service monitoring criteria.

Useful sources of information may include:

• The NICE ‘shared learning' database offers examples of how organisations have implemented NICE guidance locally, including services for the care of women with HMB, for example Developing an Abnormal Bleeding Service at Bradford and Airedale tPCT and Raising the profile of LARC in North Lincolnshire
• NICE cost impact report for CG30 on long-acting reversible contraception
• ‘Delivering the 18 week patient pathway: 18 week commissioning pathways' and the heavy menstrual bleeding pathway.
• ‘Getting it right for teenagers in your practice'
• The ‘Map of medicine' provides an information resource that visually organises the latest evidence and best practice guidelines.
• The NICE ‘shared learning' database offers examples of how organisations have implemented NICE guidance locally, including services for the care of women with HMB, for example Bradford and Airedale tPCT.

References

1. Julian S, Naftalin NJ, Clark M et al. (2007) An integrated care pathway for menorrhagia across the primary-secondary interface: patients' experience, clinical outcomes, and service utilisation. Quality and Safety in Health Care 16: 110-5

2. Nixon RM, Duffy SW, Fender GRK et al. (2001) Randomization at the level of primary care practice: use of pre-intervention data and random effects models. Statistics in Medicine 20: 1727-38.