Shortlisted for the ‘Excellence in Primary Care and Community Care Award’ in the NHS Parliamentary Awards, we talk to the GPs involved in setting up women’s health hubs across Liverpool.
It all started in 2019 during a practice training event. One of the main priorities that kept cropping up was barriers to accessing contraception. We knew that there was a need and we started to explore what could be done about it. For example, some of our practices had coil and implant fitters and some didn’t. We started to consider how we could share resources better across our practices.
North Liverpool is one of the most deprived areas in the country. We have very high numbers of unplanned pregnancies, terminations and repeat termination rates. As well as this, our LARC (long-acting reversible contraception) uptake was very low (around 13 per 1,000 women at the time). With the support and drive of our sexual health commissioner James Woolgar, we started to explore the barriers and the enablers to offering an inter-practice LARC service.
We soon learnt that it’s one thing to say you’re starting a pilot, but delivering on it is a completely different thing. Setting up the hubs took a lot of planning and it had to dovetail with the needs and interests of the primary care network. We were fortunate that the PCN were really supportive and got behind our vision.
When presenting a pilot, you must be able to make a business case for it. It was very important to demonstrate the financial viability of the services and show a ‘good day/bad day’ scenario. Even with a dedicated, enthusiastic team, these clinics can easily lose income. It was such a useful exercise to consider variable factors, such as if a patient doesn’t turn up, or changes their mind. LARC is an activity-based service, which means that if a procedure isn’t done, no income comes to the practice. We also realised the importance of using additional roles to support the workforce (such as nursing associates and pharmacists).
In terms of enablers, James Woolgar increased the local enhanced service tariffs for primary care and put in some additional fees, like a small did-not-attend payment, that helps protect the finances without overspending budgets. He also added a small inter-practice payment and recognised some of the more complex procedures such as implant removal (historically this has attracted a lower fee, though in reality this is a longer, more complex procedure than an implant insertion).
There were other components we had to consider in the planning stage. We learnt the importance of mapping out the patient journey, developing good clinical pathways and enabling shared care agreements. We designed and created a template for our clinical computer system to help ensure good documentation and patient consent.
We currently operate in six PCNs across the city, with 16 sites. We offer LARC for all indications, treatment of heavy menstrual bleeding, cervical smears, STI screening, some menopause management, ring pessaries service, a limited HPV vaccination service and sexual health advice. We have seen a 150% uplift in LARC activity across the city compared to pre-pandemic levels.
We aim to make the hubs as accessible and efficient as possible. Our PCNs use self-referral forms (via a QR code that patients can scan). This has been really valuable, especially given the difficulties in accessing primary care at the moment. Our hubs use a variety of ARRS roles which has really helped us grow the workforce and expand capacity within the service.
Access to women’s health is a huge challenge right now, and we have to improve the landscape for our patients. Split commissioning arrangements (the cause of which goes back to the Health and Social Care Act of 2012), means that fitting LARC for any indication is a huge challenge. In many areas, patients are turned away from services if their request for LARC is not due to a contraceptive need (for example an IUD for heavy periods or as part of HRT). James has broken these barriers down, by enabling a ‘claim back process’ within the ICB. The device is fitted and the responsibility for who covers the cost is dealt with retrospectively, so that patients can have timely, high quality care in a convenient way.
We need to be able to wrap services around women and that is exactly why our role as GPs is so important in setting up these hubs. General practice is a holistic profession and women’s health requires a ‘whole person’ approach. We heard this message loud and clear through the Government’s Women’s Health Strategy in 2022. It’s so important that we support the development of these services. Every one pound invested in the provision of LARC in primary care saves £48 pounds in the healthcare and non healthcare costs over 10 years. If we can prevent unplanned pregnancies or long-term health conditions by providing these services, then the return on investment is huge and far reaching. As Lord Darzi’s report said, GPs have the best financial discipline and it makes sense for the whole system to look at putting the right services in the right place for the benefit of all.
We need to start bringing women’s health back into primary care where patients want to access these much-needed services in a timely manner. We always say that ‘we are forever joining up the dots’, through linking up colleagues, building relationships, running educational forums and bulletins for our WHH teams etc. It is hard work, and you must be determined and tenacious to get things done, but it is our patients that motivate us to keep going. We all know the problems but our focus is to be part of the solution.
Dr Stephanie Cook is a GP from Liverpool with a special interest in Women’s Health. Steph is clinical lead for the Women’s Health Hubs in Cheshire & Merseyside ICB and is one of the Executive Directors of Primary Care Women’s Health Forum.
Dr Jen Peters is a GP working in North Liverpool. She also works for Axess Sexual Health and is their ‘GP Champion’ for sexual health in Liverpool.
