In the area covered by North Lambeth primary care group, birth rates among girls aged under 16 are the highest in England and Wales, at 640 per cent of average national levels, and 42 per cent of all pregnancies end in abortion (compared with 19 per cent nationally).
North Lambeth is a poor, multicultural, inner city area where 86 per cent of patients attract deprivation payments.
Lambeth, Southwark and Lewisham health action zone has identified sexual health in young people as a priority, and it is also noted as an important equity issue in the local health improvement programme.
Local primary care teams felt that contraceptive services could be improved, and all practices agreed to share data. We carried out a research project in July and August 1998 to support this.
A GP carried out a literature review to identify key quality elements for contraceptive services and an evaluation framework was developed. We then assessed appropriate staff training across the whole primary care team; acceptability of services - especially confidentiality and the choice of a female provider; availability of, and information about, a full range of services; and accessibility in terms of appointment systems and opening times.
Practice managers and senior receptionists were interviewed on the telephone and all 26 practices in the then pilot primary care group were visited. We also analysed routinely available data on prescribing, contraceptive service claims, staffing and practice leaflets.
The findings were in line with other evidence on variation between general practices in inner London. Claims for contraceptive services ranged from between 0 per cent and 75 per cent of women aged under 25 in the practice population. One practice made claims for between 70 and 75 per cent of young women registered with it. All the others made claims for between 20 and 55 per cent of young women registered.
Two of the practices had no female GP or nurse qualified in family planning, and some GPs were fitting fewer coils than the 12 a year recommended as a minimum by the Royal College of Obstetricians and Gynaecologists. Some GPs and and practice nurses were not qualified according to the agreed quality standards.1
Information about contraceptive services in waiting rooms and practice leaflets was generally limited. No leaflet carried information about alternative providers such as family planning clinics and Brook Advisory Service centres. Making appointments for emergency contraception, without breaches of confidentiality, was recognised to be a key issue, especially for reception staff.
Results were fed back to each practice at a PCG meeting and the project team has been impressed at how effective this has been at stimulating change.
There is now a real focus on improving sexual health services for young people in North Lambeth. We consider this to be a successful example of clinical governance.
A leaflet detailing local contraceptive services is being developed for use in all practices, and a training programme about confidentiality and emergency contraception for reception staff is being organised in conjunction with the Brook Advisory Service.
A set of core clinical standards has been developed by local primary care representatives and the health authority, with expert advice from family planning clinic staff. These cover confidentiality, staff training, methods of contraception, physical facilities, prescribing, cervical smears and referrals for termination of pregnancy.
The standards have now been agreed by the local medical committee and have been used in North Lambeth for a more extensive survey of family planning services and skills. This achieved a response rate of 80 per cent from practices in two weeks.
More detailed analysis of prescribing data has been carried out, and a further review of all of the results is scheduled for later this year.
1 Mawer C. Clinical Standards for Family Planning Services. Lambeth, Southwark and Lewisham health authority, 1998.
Dr Caroline Mawer is a consultant in public health medicine (primary care) at Lambeth, Southwark and Lewisham health authority. Dr Cari Free is a GP in Lambeth and research associate at the department of general practice and primary care, Guy's, King's and St Thomas' medical school. Sheeylar Macey is a practice nurse and North Lambeth PCG board member.