The Atlas of Shared Learning

Case study

Increasing the uptake of ‘Long Acting Reversible Contraception’ (LARC) in General Practice

Leading change

A practice nurse at South Wigston Health Centre led the implementation of a dedicated clinic for the fitting of intrauterine devices (IUD) or intrauterine systems (IUS). This has improved patient outcomes, patient and staff experience and use of resources locally.

Where to look

NICE (2019) reiterated the importance of good sexual health for individuals and communities. Poor sexual health can lead to unintended pregnancies and sexually transmitted infections. It is also recognised that socioeconomic status can be an important determinant in sexual health and contraceptive use. Bentley et al. (2009) demonstrated the links between social class and contraception use, noting that this varies significantly across geographies with women in lower socioeconomic areas often less likely to use contraception than women in more advantaged areas.

In particular there is a reported 6-fold difference in teenage conception and birth rates between the poorest areas in England and the most affluent areas (NICE, 2014), with variation in emergency contraception use by young women according to the level of deprivation in their area of residence (NICE, 2019). The links between sexual ill-health, deprivation and social exclusion and unintended pregnancies are having long-term impact on people’s lives as well as their experiences of services. To address this unwarranted variation, NICE (2014) recommends that professionals provide additional support to socially disadvantaged individuals and those who may find it difficult to use contraceptive services more generally.

South Wigston Health Centre provides a range of primary care services within Leicestershire. Situated in an area which serves people of a lower socioeconomic status, the practice nurse identified lower than expected uptake rates for IUD or IUS based on practice data. The practice is the only one locally that offered this service. The practice nurse saw this as an opportunity to lead change within her surgery and locality – focusing on increasing the uptake of IUD and IUS and improve experience, outcomes and use of resources locally.

What to change

The nurse and a General Practitioner (GP) identified there was no dedicated clinic for IUD/IUS fittings and these took place on an ad hoc basis. Increasingly these appointments were scheduled at the end of a morning clinic or over lunchtime when both a GP and a nurse were available. Such availability meant that appointment slots were difficult to establish, and extended wait times were occurring.

The nursing lead also identified that whilst counselling has been shown to increase concordance and acceptability of contraceptive methods (particularly LARC), these weren’t always offered or available for patients.

The practice nurse identified that a more coordinated and streamlined method of delivering contraceptive care to women was needed.

How to change

Using practice data, the nurse lead explored the services available and better ways of delivery with surgery staff and patients. The nurse worked with the GPs, Practice Managers and the nursing team to generate engagement in the improvement project. This was secured by highlighting the evidence of benefit and demonstrable commitment to addressing colleagues’ existing experience.

A designated fortnightly 2.5-hour clinic was established, explicitly for fitting IUD/IUS. Clinicians could book patients into this clinic with a view to streamlining fitting as well as effective pre-fitting counselling. An additional anticipated benefit was that women would have a dedicated appointment time with a length appropriate to their needs – tailoring the care for the patient.

This process included an experienced practice nurse undertaking an assessment of sexual health, risk of pregnancy, infection (particularly sexually transmitted infection risk (STI) and other pre-fitting support needs. This also ensured alignment to the Faculty of Sexual and Reproductive Health (FSRH) guidance.

Adding value

Better outcomes – An observed increase in IUD/IUS fittings from 1-2 per week to an average of 8 per week. This positive step can also be seen in the increased number of women attending their 4-6-week follow-up appointment with the nurse/GP now that the booking is embedded in the new process. This follow up concordance is anticipated to have a significant preventative influence as it monitors patients more readily and keeps patients engaged in their own care and management. Patients have attributed these early successes to a familiar environment and positive fitting experience. General health parameters have anecdotally improved owing to the additional provision of support.

Better experience – Patient experience has improved. Women have reported receiving more timely and effective contraception in a positive environment, delivered by highly skilled professionals. Comments included:

“I feel more comfortable”

“Familiar environment with the same nurse and doctor”

Staff have also commented that they feel better equipped to deliver optimal care for their patients in the designated clinic. They also observe that the changes are now implemented as business as usual.

Better use of resources – The work contributes to the wider prevention agenda through advocating and provided sexual health advice and appropriate contraception. This has included embedding a culture of lifelong learning across the practice and local area; developing nurse leaders and ensuring a compassionate culture. An estimated 1-2-hours per week GP time has been has released for other patient care, with nurses leading the sexual health clinic sessions.

Co-ordinated and streamlined appointments continue to enhance the delivery of this service.

Challenges and lessons learnt for implementation

Some of the challenges included resources for the whole practice team on the rationale and benefits of the new process – engagement is key in the change agenda. The practicalities of changing the appointment system and management of this were more difficult than anticipated but with the benefits already far outweigh these complexities.

Once the system was up and running there was also the challenge of ensuring the designated clinic time was protected so that the service could flourish.

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