Improving access to LARC in Liverpool – A Commissioner Perspective

With the pending Women’s Health and Sexual and Reproductive Health Strategies and the formation of the ICS (Integrated Care Systems), in this month's eFeature James Woolgar - the Sexual & Reproductive Health Commissioning Lead and Chair of the English SRH and HIV Commissioner Group - tells us about the work that has been undertaken in Liverpool and how this is improving LARC access for women in the area.

The commissioning of sexual and reproductive health services has always been a challenge in terms of system join up. However, increasingly we are devising more innovative ways to improve care and access amongst a backdrop of (as we emerge from COVID) rising demand.

There is a host of evidence to support the fact that women are disproportionately affected by the lack of co-commissioned services (fragmentation). Roughly 50% of British women experience poor sexual and reproductive health, a much higher number than men, (BMC Public Health, 9th January 2020 - Latent class analysis of sexual health markers among men and women participating in a British probability sample survey).

Additionally, there have been multiple All-Party Parliamentary (APPG) inquiries^{[1, 2]} calling for improved collaboration and integration as well as better system access in relation to contraceptive needs both pre and post pandemic. The Royal College of Obstetricians and Gynaecologists’ (RCOG) ‘Better for Women’ report of 2019 further backed this view that we very much needed to find ways to collaborate across systems and centre provision around the needs of women. The Advisory Group on Contraception (AGC) echoed this. Indeed, both recommended that we consider commissioning ‘women’s health hubs’, that build on the provision of local authority-funded contraception with other reproductive services (such as cervical screening, psychosexual services, heavy periods, menopause treatment etc) added in. This would ensure a holistic offer, a ‘one stop’ approach and would require the coming together of both commissioners and providers across their patch^{[3, 4]}.

Access to LARC, pre-COVID, required work to improve consistency, but the pandemic only served to exacerbate the issue.

Hence, we knew in Liverpool that we needed to redesign provision and manage demand more effectively (creating an online offer) to try and create more appointment space for LARC in specialist services. At the same time, we redesigned our GP offer, and commissioned ‘Women’s Health Hubs’, including broader access to a range of care for women via Primary Care Networks (PCNs). A new post-partum LARC programme also sees us provide access to contraception more routinely as part of the maternity pathway.

A Women’s Health Hub model saw the implementation of an inter-practice referral service offer for LARC (with wider condition management) via the 10 Primary Care Networks (PCNs) across Liverpool. A “hub and spoke” model allows for women to access both within their own network, and to venture outside of it. “Hubs” identified in each of the PCNs are commissioned to deliver the bulk of the work in the PCN, with non-fitting practices referring into the hubs and actively booking LARC appointments. As part of the work, we undertook a crucial audit of trained fitters, and created direct links for ongoing training and maintaining fitting competence levels back into the new integrated sexual & reproductive health service - ‘Axess Sexual Health’. A strategic training forum, with clinical fitter forums, was developed and as a result we now have a host of trained fitters in hubs located across PCNs.

At the same time, we studied the costings and viability of clinic delivery. We worked closely with Manchester commissioners and produced a wonderful costings/viability piece and worked out what we should be paying to make delivery for hubs in the networks viable. This led to a series of very clear changes to our payments, and a ‘clinic blend scenario’ workpiece that we were then able to formulate into a business case with which we could then pitch to the PCN boards.

What we now have is a fast-growing Women’s Health Hub model that sees budgets more effectively combined local authority to NHS allowing for wider use of intra-uterine systems (IUS). So, clinicians are not restrained by commissioning body. We’ve seen considerable growth in the number of appointments made available and our LARC rates locally have gone up considerably.

This has all happened due to excellent collaboration, strategic planning, robust business cases, insight, and cost modelling. Many practices, or hubs in networks, now want to provide it as it makes sense, and it continues to grow!

What does the future hold for us all? There are without doubt major opportunities to reduce fragmentation and improve care even further for women. There are opportunities via the pending women’s health strategy and the development of integrated care systems (ICS) that have the potential to address concerns around access, equity, and consistency if we prioritise this agenda and collaborate effectively. Against a backdrop of rising demand for a range of services, this will be a challenge no doubt, but one that I know many local commissioning leads will take on innovatively to make a difference in their local communities.

If you would like to speak with James Woolgar about the contents of this eFeature, please email him directly on: james.woolgar@liverpool.gov.uk

Declaration - This article is funded by Bayer and the author has received an honorarium.

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References:

1 All-Party Parliamentary Group on Sexual and Reproductive Health in the UK (APPGSRH) (2015) Breaking down the barriers: The need for accountability and integration in sexual health, reproductive health and HIV services in England

2 All Party Parliamentary Group on Sexual and Reproductive Health (APPG) (2020) Women’s Lives, Women’s Rights: Strengthening Access to Contraception Beyond the Pandemic 

3 Royal College of Obstetricians and Gynaecologists (2019) ‘Better for Women’

4 Advisory Group on Contraception (AGC) (2020) - Written evidence submitted by AGC on access to Contraception – beyond the pandemic (DEL0157)

PP-PF-WHC-GB-1069 MAY 2022