Introduction

Little has changed in the past two decades with regard to requirements for the commissioning of abortion services. The basic premise of a woman having early access to abortion care has been with us for the 42 years since abortion had been legalised in England. It is somewhat surprising that in 2010 we are still reiterating most of the same best practice advice that was published in 1994 by Birth Control Trust & Pregnancy Advisory Service in their guide entitled ‘How the National Health Service can meet the needs of Women. Abortion Services in England and Wales’. Even after 40 years’ experience of providing abortion care, we still experience incidences where we are obliged to deliver care via restrictive care pathways, which create barriers to access to abortion, and contractual arrangements which can deny women access to additional essential care. This accounts, at least in part, for the wide variation in adherence to the less than 10-week gestation key performance indicator (KPI) by primary care trusts (PCTs) ranging from 56% to 85%, highlighting huge inconsistencies across the country.

It is not all doom and gloom: in 1991, only 50% of abortions were funded by the National Health Service (NHS); and in 2009, 94% of abortions were funded by the NHS. We no longer need to encourage or convince commissioning organisations that the women of their locality have a right to abortion care funded by the NHS. Unfortunately, however, we still see some locally defined referral criteria, which can discriminate or delay a woman gaining access to early treatment. We see contract criteria, which may prevent a woman from benefitting from a full service such as contraception counselling and provision or sexually transmitted infection (STI) screening and treatment. For most NHS agency providers, the reality of this could mean that women sitting next to each other in the waiting room of one of their centres can have a completely different experience. One woman may have been able to refer herself directly without needing to first visit her general practitioner (GP) or family planning centre; she may also have access to contraception counselling with the full range of contraception choices. By contrast, the woman sitting alongside her might be finally accessing treatment several weeks after finding out she was pregnant because her local commissioning organisation dictates that she must wait for assessment by her NHS pregnancy advisory service (PAS) unit, which had a waiting list and limited opening times. Apart from the appalling disparity and inequitability in that circumstance, any delay in access means that treatment will ultimately cost the NHS more. It is unthinkable that in this day and age that a woman can be forced to continue with an unwanted pregnancy longer than necessary because of a badly designed care pathway. Some regions of the country need to revisit their referral criteria to ensure every woman, irrelevant of age, can obtain an equitable, consistent standard of care.

It is important to say, however, that once a woman is referred to a service provider, she should expect to receive the highest standard of abortion care. Quality and Clinical Standards, within this specialised area of care, are well defined not least by the Royal College of Obstetricians and Gynaecologists (RCOGs) but by many agencies involved with the provision of abortion services such the Care Quality Commission, Medical Foundation for AIDS and Sexual Health (MedFASH), etc. British Pregnancy Advisory Service (BPAS) representatives have been included in many working parties and government committees over the last 40 years, and have contributed their knowledge and experience to help define quality and clinical standards.

To address the national inequalities acknowledged and to ensure a consistent quality of a holistic abortion service, during 2009, the Department of Health gathered together a working party with representation from NHS commissioners, NHS providers and the two main not-for-profit independent providers. The intention of the working group was to define a National Service Specification for Termination of Pregnancy Services, which can be used by a commissioner as a tool to design and monitor a robust, quality abortion service for their region. The new specification, published in January 2010, has defined requirements for commissioners and providers, as well as recommending key performance indicators and monitoring mechanisms for ensuring a quality abortion service. The 2010 specification clearly defines roles and responsibilities and supplies the commissioner with a template for delivery of a holistic abortion service, including the full range of contraception and essential STI screening and treatment.

Best practice for the commissioning of abortion services

Best practice for the commissioning of abortion services

1

The purpose of a termination of pregnancy service

“The purpose of the a termination of pregnancy service is to provide abortions which are speedy and safe depending of the personal health and circumstances of the individual service user, to reduce further unintended pregnancies and abortions and to promote better sexual health among service users.”

This section of the service specification defines the aims, evidence base, objectives and expected outcomes of the service. This section also identifies some of the many standards, guidance and legislation that an abortion service must be delivered to.

Abortion services have been commissioned now for over 30 years and as such there is a ‘don’t fix it, if it isn’t broken’ mentality towards it. In addition, the budget allocation for an abortion service may be insignificant in comparison to other service spend. Abortion services may be perceived as less important. Abortion is a stigmatised area of health care and, as such, service users are unlikely to ‘make a fuss’ or complain if their expectations are not met. As the majority of service users will only use an abortion service once in their lives, the general positive outcomes for them are “I’m no longer pregnant and I was treated sensitively.” In our experience, very few service users will complain if they do not receive the other components of essential care, such as a full range of contraception or STI screening. They are just relieved to receive their abortion funded by the NHS. When you add all these factors together, abortion service development or improvement is often ‘left on the shelf’. As a result, service providers usually spend significant time trying to convince commissioners that improvements need to be made. An example being that the service specification mentioned in the introduction published by the Birth Control Trust in 1994 makes the recommendation 5.26 “All women must be offered family planning advice after the abortion and before returning home. Supplies should be provided at that time.”

The Operating Framework for the NHS in 2009 states “35. It is important that services are provided when needed most. The standard contract for 2009/10 includes the requirement that providers of abortion services should also provide contraception advice and services after an abortion has taken place. Experience of this will be monitored as part of the Patient Survey.”

However, nearly 20 years after the Birth Control Trust Service Specification publication, some commissioning organisations still preclude us from providing the full range of contraception choices to their clients.

The 2009 repeat abortion rate was 34%, which had risen from 29% since 1998.

The reasons for repeat abortion are complex and there are many factors which may have contributed to the increase in reported repeat abortion in the past 10 years. There certainly is not one solution to fix the issue; however, no one can argue that it is sound common sense to provide all contraception options at the time of treatment without handing the service user to another provider (thus enabling them to drop out of care). Had the Birth Control Trust recommendation been implemented, it may have contributed to the prevention of subsequent further unplanned conceptions and therefore had a positive effect on the rising repeat abortion rate.

Providers have been lobbying commissioners to implement these essential service improvements for many years.

Once the aims, objectives, etc. have been defined for the abortion service, it is essential to revisit them regularly to ensure they are still fit for purpose. As service users are unlikely to complain about not receiving a holistic service, the responsibility for developing and improving the service rests with the commissioners and providers.

2

Service scope

This section asks for ‘descriptions’ concerning the scope of the service. It can be difficult to visualise the total shape of a service and to identify all interdependencies relating to an abortion service. For example, where does a woman get referred to if she has complex medical problems? What happens if the woman’s gestation is over the legal limit to be treated by an independent provider? The best way to demonstrate these complex relationships is by mapping them. In providing Central Booking Services on behalf of PCTs nationally, BPAS has established working relationships with a complex ‘web’ provider combinations. Manchester PCT’s service map example may be referred to, which demonstrates the extent of its local provider services.

Example abortion service provider map

Mapping the shape of the service in this manner presents the opportunity to identify potential gaps in service (see Diagram 1 ).

Example abortion service provider map.