Tri Health (Doncaster Sexual Health Service)

Local Commissioned Service

Provision of Intra-uterine Contraceptive Device

(IUCD) Fittings

Service Specification 1 April 2015 – 31 March 2019

  1. Introduction

All practices are expected to provide essential and those additional services they are contracted to provide all their patients. This enhanced service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.

  1. Background

Evidence shows that:

(i)IUCDs make up approximately 5 per cent of contraceptive usage in the UK. This is much lower than in many other European countries.

(ii)Clinical effectiveness is excellent, with a recognised failure rate for all devices of 0.2-2.00 per woman-years. For the levonorgestrel-releasing intrauterine system (LNG-IUS) the failure rate is 0.16/100 woman-years which is comparable to female sterilisation.

(iii)It is one of two areas of contraceptive provision with relatively high levels of litigation and the most important factor influencing failure rate.

(iv)The risk of pelvic inflammatory disease attributable to IUCD usage is low at 1.5. per 1,000 If 1000 women have an IUCD inserted, then 1.5 of them will develop pelvic inflammatory disease.

(v)The World Health Organisation (WHO) supports the use of the IUCD in young women including those under 20 years provided they are at low risk of sexually transmitted infections (STI)

(vi)The LNG-IUS has additional non-contraceptive benefits of decreasing menstrual loss and is part of the management of menorrhagia recommended by the Royal College of Obstetricians and Gynaecologists (RCOG)

(vii)Insertion of copper IUCD up to 5 days after presumed ovulation acts as a very efficient emergency posy- coital contraception. Because of its increased post- coital time frame and non hormonal constituents, it is complementary to the emergency use of the progesterone-only contraceptive pill

(viii)IUCD fitting and removal is not undertaken by all general medical practitioners and maintaining expertise in IUCD fitting can be difficult.

  1. Aims

The aims of this service are to:

(i)ensure that the full range of contraceptive options is provided by practices to patients

(ii)ensure that the availability of post-coital IUCD fitting for emergency contraception should be more adequately provided as another means of reducing unwanted pregnancies

(iii)Increase the availability of LNG-IUS in the management of menorrhagia within primary care

  1. Service Outline

The national enhanced service will fund:

(i)fitting, monitoring, checking and removal of IUCDs as appropriate

(ii)Production of an up to date register of patients fitted with an IUCD. This will include all patients fitted with an IUCD and the device fitted. This is to be used for audit purposes, and to enable the primary care team to target these patients for health care checks.

(iii)Practices to undertake regular continual professional development (CPD)

(iv)Provision of adequate equipment. Certain special equipment is required for IUCD fitting. This includes an appropriate room fitted with a couch and with adequate space and equipment for resuscitation. A variety of vaginal specula, cervical dilators and equipment for cervical anaesthesia also need to be available. An appropriately trained nurse or health care assistant (CPR trained) also needs to be present to support the patient and assist the doctor during the procedure.

(v)Chlamydia screening this should be done before insertion of the IUCD and, if positive, refer for screening for other STIs. This should be in accordance with national policy.

(vi)The use of condoms to prevent infection

(vii)Regular assessment- A check of the IUCD between three and six weeks after fitting is suggested. In addition any problems such as abnormal bleeding or pain should be assessed urgently

(viii)Provision of information- Written information should be provided at the time of counselling and reinforced after fitting with information on follow up and those symptoms that require urgent assessment.

(ix)Production of an appropriate GP record- Adequate recording should be made regarding the patient’s clinical history, the counselling process, the results of any chlamydia screening, the pelvic examination, problems with insertion, the type and batch number of the IUCD, and follow up arrangements. If the patients is not registered with the practice providing the NES, the providing practice must ensure the patient’s registered practice is given all appropriate clinical details for inclusion into the patient’s notes

(x)The use of LNG-IUS for the management of menorrhagia in primary care as part of a care pathway agreed and developed with local gynaecology departments- To ensure these devices are used for the correct patients and the approved indications

(xi)An annual review, which could include an audit of:

(a)the register of patients fitted with an IUCD

(b)continuous usage rates

(c)complications

  1. Accreditation

Practitioners undertaking this procedure must have undertaken and be competent to deliver as outlined in the Faculty of Reproduction Sexual Health (FRSH) training standards. Please see Appendix 1 for details of training requirements and accreditation.

Those doctors who have previously provided services similar to the proposed enhanced service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence as is necessary to enable them to contract for the enhanced service shall be deemed professionally qualified to do so.

  1. Costs

Each practice contracted to provide this service will receive a £79.90 insertion fee per registered patient, £100 insertion fee per non-registered patient and a £21.32 removal fee per patient (if device not fitted at practice) The invoice template and claim form are at Appendix 2.

On behalf of Tri-Health / On behalf of GP Contractor
Signature /
Name / Helen Burroughs
Position / Deputy General Manager
Children & Families Care Group, DBHFT
GP Practice
Date:

Appendix 1

1.1 The practice has a duty to ensure that doctors and nursing staff involved in the provision of the service have relevant knowledge and are appropriately trained and competent in the operation of the service. Practitioners should be familiar with the NICE[1] guidance on long acting reversible contraception and should be working in compliance with this guidance at all times. Specifically, clinicians should be competent in resuscitation, demonstrate a continuing sustained level of activity, conduct regular audits, be appraised in what they do (either as part of GP appraisal or by a suitably qualified General Practitioner (GP)/nurse in the case of nurses) and take part in necessary supportive educational activities. Those holding the Letter of Competency (LoC) Intrauterine Techniques (IUT) or equivalent need to recertify on a regular basis. Those holding an up to date accreditation letter issued by a lead clinician for contraception and sexual health in the Local Authority need to follow the same recertification process as those with LoC IUT and or SDI or equivalent qualifications.

1.2 The practice has a duty to ensure that doctors and nursing staff involved in the provision of the service are aware of and operate within local protocols concerning local anaesthetic use, decontamination procedures and handling of clinical waste. The practice must have infection control policies that are compliant with national guidelines including the handling of used instruments, excised specimens and the disposal of clinical waste. The practice is responsible for effective operation and maintenance of sterilisation equipment used in the practice

1.3 Tri-Health will alert all practitioners providing this service to any urgent incidents or contraindications relating to Intrauterine Techniques (IUT) and Subdermal Implants (SDI).

1.4 The practice should co-operate with any locally agreed City Council led assessment of service user experience

Faculty of Reproductive Sexual Health (FRSH) Service Standards 2013.

NICE. Long Acting Reversible Contraception GC30.

2. Accreditation

It is required that practices and practitioners undertaking procedures hold either:

2.1 For GPs, an up to date FSRH Diploma in Sexual and Reproductive Healthcare or equivalent and an up to date letter of competency in contraceptive IUT insertion and removal (LoC IUT) and LOC for Subdermal Implant insertion and removal.

2.2 For nurses, a recognised up to date accredited reproductive and sexual health (SRH) qualification with 2 years’ post qualification experience followed LoC in IUCD insertion and removal and LoC for Subdermal Implant insertion and removal and may hold Nursing FRSH Diploma in Sexual and Reproductive health.

OR

2.3 An up to date accreditation letter issued by a lead clinician for contraception atTriHealth (Doncaster Sexual Health Service) giving approval that the practice and practitioners undertaking contraceptive IUT and subdermal Implant procedures are fit to practise.

In addition the practice will undertake not to refer to the community sexual health services for IUT and Subdermal Implant fitting and review procedures except for the fitting of an emergency coil and/or where there are coil fitting difficulties which require a more experienced provider.

Training Requirements for the Letter of Competence in Intrauterine Techniques[2]

3.1 Clinical training

A minimum of seven competent insertions of intrauterine devices, in women who have agreed to take part in the training process, must be undertaken. All accredited insertions must be in conscious women.

Trainees may include a maximum of five satisfactory IUD/IUS insertions, in conscious women, supervised during training within previous 12 months or concurrent training. Any insertions carried forward in this way must be documented on the LoC IUT application form, and signed off by the supervising practitioner.

These five insertions may be accredited from:

  • Previous/concurrent training under the supervision of a Consultant Gynaecologist.
  • Previous/concurrent training in General Practice under the supervision of a GP Trainer or a GP experienced in intrauterine techniques, with the agreement of the GP Trainer.
  • Previous training for RCN IUT competencies under the supervision of an FRT.
  • In order to achieve/demonstrate competency, it is not uncommon for more than 7 insertions to be required.
  • Satisfactory insertions must include at least two different currently available devices, which must include a hormonal and a ‘gold standard’ copper device.
  • It is recommended, but not required, that each trainee have more than one trainer.
  • At least two competent insertions must be supervised by the Primary Trainer.
  • In addition, trainees must demonstrate the ability to conduct an appropriate sexual health consultation

Practical training must continue until the Primary Trainer is satisfied with the level of competence achieved by the trainee. ALL training experience (both theory and practical) must be recorded on the LoC IUT application form.

3.2 Practical training (experienced practitioner route)

Model uterus training

The experienced practitioner must demonstrate competence in insertion in a model uterus before competence is assessed in live patients.

Log of self-certified insertions

A log of six IUD/IUS insertions, in conscious women, undertaken during the previous 6 months may be self-certified.

Clinical training

A minimum of two competent insertions of intrauterine devices, in women who have agreed to take part in the training process, must be undertaken. All accredited insertions must be in conscious women.

  • Satisfactory insertions must include at least two different currently available devices, which must include a hormonal and a ‘gold standard’ copper device.
  • At least two competent insertions must be supervised by the Primary Trainer
  • In addition, trainees must demonstrate the ability to conduct an appropriate sexual health consultation

3.3 Revalidation

Practitioners must meet the standard requirements outlined by the FRSH and evidence a log of 12 insertions covering a consecutive 12 month period with 24 months of the recertification date, showing at least 2 different types of intrauterine methods in conscious women.

Appendix 2

Comments or Special Instructions
Quantity / Description / Unit Price / Total

Bank Name:

Sort Code:

Account Number:

Before submitting your Invoice please check it complies with the following:

  • Clearly states if it is an Invoice or Credit Note
  • Provide clear details of the organisation submitting the invoice ad includes the remittance address
  • Provides clear details of all Goods/Services billed
  • Is legible
  • Has a valid invoice date (Tax Point) and Invoice Number
  • Clearly states the payee
  • Has the correct VAT Calculations (Handwritten invoices in particular)
  • Invoice adds up correctly (Handwritten invoices in particular)
  • Includes the relevant supporting information, for example 1 claim form

Revised September 2016

Tri-Health Contract CLAIM FORM

IUCD’s & IUS

Date / NHS Number / Fitting
Reg patient which includes Fitting. 6 week check and removal / Fitting non-reg patient which includes Fitting. 6 week check and removal / All prep work completed fitting not appropriate (non reg patients only) / Removal that was NOT fitted by the practice / Name of Individual performed procedure / Other please give details and see fee schedule
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9
10

I declare to the best of my belief that this information is correct and Authorised signature

I claim the appropriate payment as set out in the Tri-Health SLA. An

Audit trail is available at the practice for inspection as necessary.

Name:

Date:

PLEASE RETURN FORM TO: Liane Leak, Assistant Business Manager, Tri-Health, Doncaster Royal Infirmary,

Armthorpe Road Doncaster DN2 5LT

Revised September 2016

[2]The Faculty of Sexual and Reproductive Healthcare.Letter of competency in Intrauterine Techniques 2015.