Oxfordshire County Council has worked closely with local GPs to ensure women have access to LARC and the system is administered fairly in terms of whether it is the council or NHS that pays for the service. This case study forms part of our sexual health resource.
In 2014 Oxfordshire County Council introduced an integrated sexual health service. This merged the previously separate contraception and STI treatment services into one service.
It provides a ‘one-stop shop’ model where residents can access services that meet all their sexual health needs in the one place delivered by the one team in nine clinics across the county.
With that system well and truly embedded, the council has turned its attention to working more closely with GPs to ensure that additional services provided in general practice remain an option for women.
GPs are commissioned by both the NHS and councils to provide contraception services. This fragmentation can cause confusion over who is responsible for paying for what and the support doctors get in providing services to patients.
Oxfordshire is recognised as a national exemplar in terms of championing training and the development of the GP workforce. The council ensures this through funding training through the integrated service contract.
The contract specifies that the provider, Oxford University Hospitals Trust, is responsible for training GPs and their practice staff. This is offered to both new and existing members of GP teams through introduction and refresher training in how to administer LARC and when it is appropriate to use.
Since the service began in 2014 the service has trained 74 local practice staff to deliver LARC as part of local commissioned services.
The council has also worked with the local CCG to establish a clear system for who is responsible for paying for LARC.
LARC can be prescribed for a variety of reasons. The most obvious use is as a contraceptive, but GPs also prescribe it for other reasons, including as part of a hormone replacement therapy for menopausal women and to help patients manage heavy menstrual bleeding.
Public Health Consultant Dr Eunan O’Neill said: “Where it is used as a contraceptive, it is the council’s responsibility to pay, but if it is for a medical condition it is an NHS issue. When we looked at this we found this was confusing for GP practices who were not clear on who to bill.
“There was a concern that developing complicated procedures to sort out the billing could lead to women not being offered LARC.
Last year the council worked with the CCG to establish a legal section 256 agreement to commission non-contraceptive use in GP practices on its behalf. This secured the delivery of contraceptive and noncontraceptive use of LARCs for women across the county.
Dr O’Neill is delighted with the result. “The arrangement ensures that GPs do not have to consider which organisation is contracting their services and reduces duplication of monitoring and managing services for commissioners.”
Local GP Dr Elizabeth Van Stigt said: “Over time, the use of intrautering systems (IUSs) for non-contraceptive purposes has increased hugely, so it seems only right that the NHS shares in this cost. “In reality most IUSs are fitted for a combination of reasons or the reasons change over time. It therefore makes absolute sense that GPs are able to offer them in a holistic way without needing to separate the particular benefits according to payment and be paid appropriately for doing so.”
Getting payment systems right for sexual health services is difficult, but a crucial part of developing and improving services, according to Dr O’Neill.
The system for paying GPs for LARC is based on an algorithm developed by clinicians at Oxford University Hospitals, the local provider of STI testing.
It uses the records filled in by the GPs that record the reason for the contraception being given and then codes that as either a contraceptive reason or medical reason or both. Where it is both, the NHS and council share the cost.
“You have to be realistic about this. There are some cases where it is a grey area about whether it is for a medical need or for contraception. We don’t see any point arguing about or chasing up the GP so we have agreed we just split the costs,” Dr O’Neill added.
How the approach is being sustained?
The public health team is constantly looking to improve the way services are provided through its commissioning.
In April a new contract was introduced for online services including self-sampling for STI tests and access to repeat oral contraception prescriptions.
The sexual health promotion and outreach arm of the service has also been asked to engage with high-risk disenfranchised groups in the community and promote safe sexual health behaviours.
Dr O’Neill said: “School health nurses provide outreach in schools and colleges, but we want to do more by working with groups such as sex workers and the homeless. Oxford University Hospitals is going to be working with the Terrence Higgins Trust to develop this.”
Dr Eunan O’Neill
Public Health Consultant, Oxfordshire County Council