In 2008, in total there were 202 158 abortions performed in England and Wales and 13 817 in Scotland, unfortunately one of the most common gynaecological procedures. ‘Care closer to home’ applied to this service, as part of a holistic integrated care pathway, can improve access and choice and reduce cost whilst continuing to focus on clinical quality and safety and work towards reducing the number of primary and repeat abortions. Whilst constraints remain within Law, there are ways to change services to help reduce barriers to access not just to abortion but also the essential allied interventions of contraception, sexual health and counselling and support. The first will be reflected in the number of women able to have their abortions earlier, therefore more safely and at lesser cost. It would build on service changes to date, which has allowed women more choice of the method of abortion. The integration of contraceptive services should impact positively on the currently high level of repeat abortions. Bringing care closer to home, into the communities within which women spend their lives, is an important strategy in addressing the quality agenda in abortion care.
Political agenda
‘Care close to home’ is high on the current political agenda. The strategic case for a shift in care closer to home – and into homes – has been widely accepted for some time and was a focus for the white paper ‘Our health, our care, our say’ in 2006 and was clearly laid out in Delivering care closer to home: meeting the challenge.
A central theme to the ‘High Quality Care for all: NHS Next Stage Review Final Report’ in which sexual health was prioritised as one of the six key goals of the National Health Services (NHS), is providing more personalised services. This entails more information and choice to service users and the public, working in a range of partnerships and supporting further development and flexibility in the provision of primary and community health services. This underpins the drive to bring care closer to home and ultimately deliver better care for patients ( Fig. 1 ).
This was further re-enforced in the Chief Executive of the NHS letter to all chief executive officers (CEOs) and Chairs of Trust and Strategic Health Authorities (SHAs) in England delineating the priorities in the NHS operating framework for England (2010/11) and the policies in this year’s document, intending to highlight the four areas of quality, risk, system characteristics and integration. In the context of abortion care, the last two are particularly applicable to the acute sector, which, together with the independent sector currently provides the vast majority of abortion services ( Fig. 2 ).
Sexual health strategic background and drivers for change
In 2008, the Sexual Health Independent Advisory Group (SHIAG) commissioned a review of the 2001 National Sexual Health Strategy. The extremely comprehensive report recommended a raft of strategic aims, including improved access to NHS-funded early medical and surgical abortion, 2nd trimester abortion and extending locations for abortion services to community-based settings.
It reiterated the waiting time targets included within the 2005 Royal College of Obstetricians and Gynaecologists (RCOG) guidelines , that, as a minimum standard, all women who meet the legal requirements are offered an assessment appointment within 2 weeks of referral, can undergo the abortion within 2 weeks of the decision to proceed being agreed upon, and the referral–procedure interval be no longer than 3 weeks (RCOG recommendation 7). These guidelines are currently being updated. The Mandated Specification for Termination Services has brought this time interval down by directing all service users should be offered an appointment within 5 calendar days of referral or self-referral and all who decide to proceed with an abortion should be offered an appointment for the procedure within 7 calendar days after the decision to proceed has been taken.
The SHIAG review of contraception and abortion identified that as a commissioning issue, there is still considerable inequity in abortion access and provision. Addressing the disparities that exist in abortion services is one of the targets of the Equality Impact Assessment for National Sexual Health Policy. It is known, for example, from research on mid-trimester abortions that women under the age of 18 are significantly more likely than older women to report delays in the early stages of the decision-making process and from English national statistics that some black and ethnic minorities (BME) groups have higher rates of unintended pregnancy and abortion and repeat abortion.
The ‘care closer to home’ vision is that acute services will still be an absolutely vital part of service provision, but it will be possible for an increasingly large proportion of the care pathway to be delivered outside of a hospital setting, making greater use of community-based services. The potential for new technology, with its mobility, flexibility and rapid transfer of information to support far greater levels of service in home and community settings is significant, as we are already starting to see in telecare services and in the transfer of diagnostic services into the community in abortion as in other areas of gynaecological care ( Fig. 3 ). Challenges to establishing ‘care closer to home’ in gynaecology have been identified including cost and cost-effectiveness, impact on allied services and workforce development ( Fig. 4 ). Nevertheless, it was agreed that closer collaboration between gynaecology, sexual and reproductive health services and primary care should be encouraged at all levels and various models were considered. The ability to shift abortion care from traditional secondary care settings will depend on the skills and experience of (and facilities available to) health-care professionals in the community – general practitioners (GPs), GPs with a special interest, specialist nurses, consultants in community sexual and reproductive health, speciality doctors working in community settings, and allied health professionals (AHPs) such as pharmacists and sonographers.
Sexual health strategic background and drivers for change
In 2008, the Sexual Health Independent Advisory Group (SHIAG) commissioned a review of the 2001 National Sexual Health Strategy. The extremely comprehensive report recommended a raft of strategic aims, including improved access to NHS-funded early medical and surgical abortion, 2nd trimester abortion and extending locations for abortion services to community-based settings.
It reiterated the waiting time targets included within the 2005 Royal College of Obstetricians and Gynaecologists (RCOG) guidelines , that, as a minimum standard, all women who meet the legal requirements are offered an assessment appointment within 2 weeks of referral, can undergo the abortion within 2 weeks of the decision to proceed being agreed upon, and the referral–procedure interval be no longer than 3 weeks (RCOG recommendation 7). These guidelines are currently being updated. The Mandated Specification for Termination Services has brought this time interval down by directing all service users should be offered an appointment within 5 calendar days of referral or self-referral and all who decide to proceed with an abortion should be offered an appointment for the procedure within 7 calendar days after the decision to proceed has been taken.
The SHIAG review of contraception and abortion identified that as a commissioning issue, there is still considerable inequity in abortion access and provision. Addressing the disparities that exist in abortion services is one of the targets of the Equality Impact Assessment for National Sexual Health Policy. It is known, for example, from research on mid-trimester abortions that women under the age of 18 are significantly more likely than older women to report delays in the early stages of the decision-making process and from English national statistics that some black and ethnic minorities (BME) groups have higher rates of unintended pregnancy and abortion and repeat abortion.
The ‘care closer to home’ vision is that acute services will still be an absolutely vital part of service provision, but it will be possible for an increasingly large proportion of the care pathway to be delivered outside of a hospital setting, making greater use of community-based services. The potential for new technology, with its mobility, flexibility and rapid transfer of information to support far greater levels of service in home and community settings is significant, as we are already starting to see in telecare services and in the transfer of diagnostic services into the community in abortion as in other areas of gynaecological care ( Fig. 3 ). Challenges to establishing ‘care closer to home’ in gynaecology have been identified including cost and cost-effectiveness, impact on allied services and workforce development ( Fig. 4 ). Nevertheless, it was agreed that closer collaboration between gynaecology, sexual and reproductive health services and primary care should be encouraged at all levels and various models were considered. The ability to shift abortion care from traditional secondary care settings will depend on the skills and experience of (and facilities available to) health-care professionals in the community – general practitioners (GPs), GPs with a special interest, specialist nurses, consultants in community sexual and reproductive health, speciality doctors working in community settings, and allied health professionals (AHPs) such as pharmacists and sonographers.
Current provision of care
Abortion care is provided by both the NHS and the independent sector. Indeed, in 2008 , the proportion funded under NHS contract in England and Wales had risen to 91%, 53% being performed in approved independent sector places under NHS contract compared with 25% 10 years ago. (In Scotland by comparison, 99.6% were carried out in NHS premises in 2008. ) Opening up the market in England has undoubtedly increased access to services and driven down waiting times. The percentage performed at 3–9 weeks gestation has risen from 13% in 2003/4 to 73% in 2008; if we are to look at new ways of working to bring care closer to home, it is this gestation band which provides opportunity. Above this gestation, the geographical sitting of the required more expensive staffed outpatient or bed-based units is more likely to be dictated by available facilities, workforce and economy-of-scale provision, especially in view of the lower numbers at later gestations. The percentage of abortions performed after 12 weeks gestation has remained fairly static, at 10–13% over the past 10 years.
Of significance is the impact on training, both medical and nursing, of shifting out of contracts with NHS hospitals to community providers and the independent sector. To date, most contracted training takes place within the shrinking NHS provider sector. RCOG has identified this issue must be addressed urgently if a skilled medical workforce is to be preserved , and to this end, specialist training has been included in the Mandated Specification for Termination of Pregnancy Services In the USA, tailored programmes have been very successful in placing abortion care on the training agenda for obstetric and gynaecology residents. Furthermore, if medical students are not exposed to women requesting abortion care and their many and varied reasons for doing so, they cannot make an informed personal choice as to whether they wish to participate at any level in such services in their future careers.
To achieve quality provision closer to home will require provider organisations working in partnership using care pathways. Only thus can best-value woman-centric care be commissioned within a quality governance framework. Networking services and adhering to care pathways (even with unusual referral routes as may be required from marginalised groups such as schoolgirls, substance misusers and ethnic minorities) streamlines care and reduces unnecessary or inappropriate outpatient visits to improve outcomes. In many cases, follow-up care can also be provided in community settings and the patient referred back to her GP with a management plan, thereby improving both conversion rates from secondary care outpatient clinics to community care and new patient to follow-up ratios. Examples of care pathways exist, which can be adopted and adapted and robust clinical governance will ensure high standards of care. A diagrammatic representation of a local abortion-care pathway is illustrated in Diagram 1 .
Future provision of care
It is very clear what a quality holistic abortion service is considered to contain and all fit with the ‘care closer to home’ agenda. Service standards are laid out in Recommended Standards for Sexual Health Services numbers 3,5,8 and 9 , clinical guidelines are laid out in the RCOG Guideline, the Care of Women Requesting Induced Abortion (currently undergoing review) and clinical standards in Standards in Gynaecology and a service specification for termination of pregnancy services to support world-class commissioning in the Acute and Community Services have been published in Guidance on the NHS Standard Contract for Community Services 2010/11 in January of this 2010.
In the Abortion Act , (which only applies to England, Scotland and Wales) the Law is clear on requirements for where abortions can be undertaken. Current legislation stipulates that, except in an emergency, an abortion must be conducted in an NHS hospital or a place approved by the Secretary of State. This takes no account of method of abortion; in 1967, only surgical methods under general anaesthesia were available. Current treatment regimes ensure that both early medical and surgical abortion procedures are very safe and effective. The Secretary of State for Health was granted the power by Parliament in the amendments to the Act, as contained in the Human Fertilisation and Embryology Act (1990) to approve places specifically for medical abortion known as a ‘class of place’. To date, this power has not been exercised. Currently, the administration of both the antiprogestin and the prostaglandin analogue elements of medical abortion have to take place in an approved place as do all surgical procedures. This means that all abortions currently take place in NHS gynaecology wards, day care or outpatient units and private clinics.
The House of Commons Science and Technology Committee undertook to review the scientific, medical and social changes in relation to abortion that have taken place since 1967 to inform Members of Parliament (MPs) when considering options for changes in the law when reviewing the Human Fertilisation and Embryology Act in 2008. Consideration was given to where abortions could be carried out with a view to (at some point) enabling a woman’s home to be considered appropriate for the administration of the second stage of medical abortion. After taking evidence, the committee “concluded that, subject to providers putting in place the appropriate follow-up arrangements, there is no evidence relating to safety, effectiveness or patient acceptability that should serve to deter Parliament passing regulations which would enable women who chose to do so taking the second stage of early medical abortion at home, or that should deter Parliament from amending the act to exclude the second stage of early medical abortion from the definition of ‘carrying out a termination’. This would enable a trial to take place and; we invite Members of Parliament to consider our conclusions when considering the question of whether the 1967 Act should be amended or regulations passed to enable the second stage of early medical abortion to be self administered in a woman’s home.” To date, this has not happened. However, it is the subject of an application to the High Court to establish that it would be lawful for providers of early medical abortion services to issue the prostaglandin analogue (commonly misoprostol) for use in the completion of early medical abortion following discharge from licensed premises, (Ann Furedi, British Pregnancy Association (bpas), personal communication).
Until the ‘class of place’ issue is resolved, abortion procedures will remain relatively inaccessible to some women. Both medical and surgical early abortion in a community setting is standard practice in other countries.
The Department of Health commissioned a project to assess the safety, effectiveness and acceptability of early medical abortions in community medical settings. The project evaluated well and the report was published in 2008.
From this, the Department of Health is working towards developing a protocol for provision of early medical abortions (EMA) within a community medical setting. This will be drafted in accordance with Section 1(3A) of the Abortion Act 1967, which gives the Secretary of State the power to approve a community medical setting as a ‘class of places’ that meets the requirements of the protocols for the provision of EMA in England. This, however, will not address the issue of moving early surgical procedures closer to home.
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