Contraceptive services are struggling as PCTs direct budgets to the GUM target. Family planning needs a target of its own, reports Helen Mooney

For every£1 spent on contraceptive services,£11 is saved in associated costs borne by the NHS, according to the FPA. Yet despite this, contraceptive clinics and services up and down the country are facing closure or reduced services.

A recent survey by the Faculty of Family Planning and Reproductive Health Care reveals that 40 per cent of the current 207 community sexual and reproductive health service clinics are having to reduce services either by closing walk-in sessions when full, accepting only a fixed number of patients, or only seeing people with urgent problems.

This is despite being one of the 'Selbie Six' set of priorities last year, and health minister Caroline Flint's repeated promises that the government is committed to sexual health. So why are contraceptive services battling for survival?

According to faculty vice-president Dr Christine Robinson, the problem comes down to economics - many primary care trusts have allocated little or no money to fund services.

'Money is not getting from PCTs to contraceptive services because there is no target like there is for genito-urinary medicine,' she says. Although she thinks the 48-hour GUM access target is a good thing, she is disappointed that sexual health money does get through to contraceptive services.

Dr Robinson says contraceptive clinics are turning to the faculty for guidance on how to keep services open. 'The understanding within PCTs about what these services are for is very poor, there needs to be good clinical leadership and clinical interaction with management to ensure services are provided and protected,' she says.

Closure threats

Dr Robinson adds that during 2006 the faculty responded to at least five consultations across England where PCTs were seeking to close an entire community contraceptive service and were not replacing retiring service leads.

The report warns that the closure of such services not only has a marked effect on the community they serve, but also on specialist contraceptive and sexual health training available to NHS staff.

Seventy per cent of the 129 clinics that responded to the survey provided training for a diploma in family planning for medical practitioners, and nearly 73 per cent trained doctors to give long-acting reversible contraception (LARC), including fitting intrauterine devices and implants.

'These clinics provide around 80 per cent of all sexual health and contraceptive training for NHS staff; if we lose them then we won't have the trainers to train primary care staff to give this advice and service to the community,' Dr Robinson warns.

The provision of LARC is something the survey also draws on, reporting that only four of the clinics that responded had benefited from increased funding to implement the choice of LARC for all female patients who want it. This is despite National Institute for Health and Clinical Excellence guidance which recommends that all women should be offered a full range of choice in contraception.

Baroness Gould, chair of the Independent Advisory Group on Sexual Health and HIV, agrees that the argument for protecting and providing contraceptive services is an economic one.

'We need to persuade politicians to ensure the money gets through by convincing them it is cheaper to prevent than to treat,' she says.

Baroness Gould also wants to see a contraceptive target and suggests that when the 48-hour GUM target comes to a close next year it should be replaced by one for contraceptive services: 'I want to see a target that moves the NHS towards proper provision so patients are seen within 48 hours; something for contraception which is as tight as GUM is now.'

Baroness Gould would also like the Department of Health to publish its contraceptive services audit. The audit, which began in 2004 after the Choosing Health public health funding was announced, has been delayed and the sexual health lobby is bemused by its absence. Baroness Gould and Ms Robinson are both resigned to the fact that most of the 2005 information will now be out of date.

Asked in the Commons in March when the DoH was expected to publish the findings, Ms Flint could only say 'shortly', although she added that the government was also developing best practice guidance on reproductive healthcare, which she said would 'address the key issues arising from the review'.

Baroness Gould wants the DoH to carry out a 'proper review of contraceptive services' following on from the audit, and she wants yearly monitoring of what is happening on the ground. 'We need a baseline so we know what we have now, a review, monitoring, and ideally a target as well,' she says.

Bleak picture

A summary of London's community contraceptive service staffing and cuts compiled in October and November last year and updated in March paints a bleak picture.

It catalogues a plethora of cutbacks, delays and reductions in contraceptive provision across the capital.

Among others it details Bexley Care trust, which is closing all of its 'generic' contraceptive services and making its substantive family planning staff posts redundant; Wandsworth PCT, whose contraceptive clinics are 'understaffed and women repeatedly turned away from walk-in sessions'; Harrow PCT, which has had to cancel or 're-jig' clinics when staff are off and has a 'restriction of supplies and services countering NICE recommendations on LARC'; and Lambeth PCT, which has a 'formula in place to close clinics when 'overwhelmed' with patients'.

Terrence Higgins Trust deputy chief executive Paul Ward admits the situation is bad: 'There are gaping holes in service provision in many parts of the country despite the best efforts of local clinicians,' he argues.

As the London summary suggests, Mr Ward says that where clinics do exist, women often face difficulties getting appointments or accessing the range of contraceptive methods which should be available. 'It's the old story of clinics trying to do more, for more people, with less,' he says.

And Mr Ward feels the solution in fairly straightforward: 'We need investment and service redesign. Integrating contraceptive and sexual health services would increase capacity, drive down costs and eliminate unnecessary duplication. The benefits to patients, staff and public health would be manifold.'

Dr Connie Smith, a member of the independent advisory group on sexual health and HIV and co-director of contraceptive services for Kensington, Brent, Westminster, and Hammersmith and Fulham PCTs, agrees. She wants to see all PCTs carry out the needs assessment they should have done on the back of the 2001 DoH sexual health strategy.

'PCTs need to look at what is needed for their population and build capacity to meet that need properly', she says.

FPA (formerly the Family Planning Association) chief executive Anne Weyman agrees. 'Most PCTs are doing absolutely no analysis on the link between what they are spending on abortion and spending on contraception.

'They are not really looking at what's going in their populations or mapping provision in their areas, it's as if contraceptive service provision is not really on their antennae. They can make a huge difference in simple economic terms.'

Ms Weyman wants all PCTs to look in depth at their contraceptive provision and equate that to the money they spend on abortion and sexually transmitted infection. She also wants GPs and contraceptive clinics to be working much closer together, led by PCTs.

'PCTs can access the contraception prescribing records from clinics and GPs and look at the pattern of use and whether they are offering a comprehensive choice to patients. This will give us a measure of access and what is actually happening.'

She also wants to see greater support from government. 'It needs to show leadership and show that it matters. We know local areas focus on things identified by government and which the government says are important, clearly having an indicator or target that PCTs have to report on would help'.

And Dr Smith adds that the problem has been exacerbated by the current NHS financial situation and the 'redefinition' of the NHS over last few years. 'Shifting the Balance of Power and Commissioning a Patient-led NHS have left these fragile clinics shaken to the point that it is dangerous for patients not getting the services they need,' she says.

Another question being asked about the cutback of contraceptive services is how, just as the government is keen to roll out the choice agenda, does it seems that choice in contraception appears to be fast disappearing?

Immaculate contraception

The FPA's 2005 report The Economics of Sexual Health showed that increasing the range of contraception services leads to reduction in unintended pregnancies through women being able to obtain the method they prefer, and, therefore, increased compliance.

Dr Smith is concerned that just as the government is trying to expand patient choice, its development is already being curtailed in contraceptive services.

'It really hacks me off that while on the one hand woman are choosing to come to the clinics, choosing to access the clinics that are open in the evening, and trying to make an informed choice about the contraception they use; on the other hand these services which provide choice are being dismantled and undermined.'

Ms Robinson calls for local and national action. 'We are really concerned that patient care is suffering in community-based sexual and reproductive health services, and disinvestment is really restricting client convenience and choice.

'We need urgent action at local level to support community services if patient access, training and quality of care are to be maintained in sexual and reproductive health.'