General practice is many people’s first port of call for contraception advice and provision, but workforce shortages, alongside funding issues and staff training gaps, have sparked concerns over access to these services, reports Megan Ford
A shortage of general practice nurses (GPNs) and those trained to fit increasingly popular coils and implants is having a ‘major impact’ on the provision of contraception care, with patients being referred elsewhere and facing lengthy wait times.
The situation is worrying GPNs, who are recognised as vital to delivery of sexual and reproductive services and, according to the Faculty of Sexual and Reproductive Healthcare (FSRH), make up the largest component of the workforce within this area of care.
Among the key concerns is a decline in provision of long-acting reversible contraception (LARC), such as implants and coils, prompted by a shortage of specialist nurses able to fit them. Figures suggest LARC methods are gaining popularity1, but practices are struggling to keep up with demand, leaving those wishing to use these methods ‘disadvantaged’. They can face long wait times, and in some cases be forced to travel to other practices or sexual health services.
GPNs have told Nursing in Practice of persistent and growing ‘barriers’ to meeting the needs of people seeking contraception services.
‘Major impact’ of staff shortages
Ruth Bailey, an advanced nurse practitioner for sexual health and nurse representative to the FSRH Council, says ‘high rates’ of GPN vacancies are having ‘a major impact on the provision of contraception’.
‘The majority of contraception is issued in primary care but there is a workforce crisis with GPNs,’ she says.
A complex cocktail of poor pay, terms and conditions, an ageing workforce and lack of succession planning has led to a ‘real issue with staffing in general practice’, warns Ms Bailey.
The government has this year confirmed new funding to set up at least one women’s health hub across every integrated care system in England. The aim is to improve access to care for contraception, menstrual problems, pelvic pain and menopause. But without adequate staffing, it’s questionable how effective these will be.
‘I think one of the real barriers to women accessing contraception is the lack of provision of practice nurses,’ Ms Bailey says. ‘And I don’t think that is going to be fully addressed until nurses in general practice have standardised contracts that reflect their expertise and skill in a way that is fair and transparent.’
NHS Digital figures2 suggest there were 16,952 full-time-equivalent GPNs working in England as of July 2023 – up just 1.3% year-on-year. And at 23,369 the total GPN headcount is actually slightly down on last year.
And research by the Health Foundation3 projects that, under current policies, the full-time-equivalent GPN shortfall could almost quadruple, from an estimated 1,700 in 2021/22 to around 6,400 by 2030/31. This would be equivalent to nearly one in four posts.
Rising demand for LARCs
While there are not enough nurses in general practice ‘across the board’, says Ms Bailey, practices also lack staff trained to fit LARCs, as well as registered trainers who can support nurses to develop these specialist skills. And this is having a negative impact on patient care.
Government statistics released earlier this year and analysed by the FSRH1 show demand for LARC methods is increasing in England but provision within general practices and wider sexual health services has not returned to pre-pandemic levels. Latest data show that total prescribed LARC, excluding injections, stood at 41.8 per 1,000 in 2021 – much lower than the 50.8 in 2019.
While many services were reduced during the pandemic, including face-to-face contraception appointments in practices, Ms Bailey says many of those providing LARC ‘have not been re-established’.
‘We certainly know that the provision of LARCs is less than it was before the pandemic and that means women are disadvantaged,’ she tells Nursing in Practice.
The provision of contraception is a specialist skill, and in order to fit and remove LARC devices nurses must undertake additional training. But Ms Bailey highlights the difficulty nurses face in accessing those courses.
There is ‘no incentive for GPNs to undertake training to become LARC fitters. A shortage of trainers, plus no funding for backfill while nurses train, means a lack of LARC fitters’, Ms Bailey says.
‘This means many GP practices cannot offer LARC, so patients face referral to other practices or sexual health services, resulting in long waits or long travel,’ she adds.
She also suggests there has been a ‘rise in unplanned pregnancy and a rise in the demand for abortion’, claiming this is ‘the direct result of underfunding in women’s health and underinvestment in nursing in primary care’.
She concludes: ‘Put simply, contraception is a basic human right and should be easy for women to access. The situation now is unacceptable and failing women.’
Education is key
Meanwhile, women’s health nurse Donna Loose, who runs the women’s health service in her general practice in North Norfolk, says she knows of some clinicians who felt they lost LARC competencies during the pandemic when they stopped fitting them. ‘So, we’ve lost a few fitters from that point of view, because they didn’t pick the competencies up again,’ she tells Nursing in Practice.
More widely, Ms Loose feels more needs to be done to educate the workforce in general practice around contraception services and their value. She believes ‘women’s health has always been on the back burner in general practice’ because it ‘doesn’t have the financial incentive’ of services like diabetes and asthma checks.
‘But it can be seen that we need more education out there to make it an equal health condition to long-term disease management,’ she says. ‘Because I always think women’s health will be a long-term health condition.’
Ms Loose also highlights the use of contraception services by transgender patients, noting that specific training around supporting these patients is ‘not that well provided generally’. Training around caring for patients within the LGBTQ+ communities in primary care is included within modules, but it is only done ‘lightly’, she adds.
‘I tend to lean on what the patient is telling me about how [these issues] affect their emotional and psychological wellbeing,’ she says.
Ms Loose also spends time working in schools to educate young people about the issue of contraception. She says that, when doing so, she discusses ‘contraception as hormones to prevent menstruation’ in order to counter ‘the association it can only be taken as a contraception’.
Young people in particular face barriers to accessing contraception because they ‘do not know where to access it or whether they should access it’, adds Ms Loose. She therefore sees her role in educating school pupils as essential to improving knowledge and accessibility.
Staying up to date
Meanwhile, Helen Lewis, an advanced nurse practitioner in a general practice in Cardiff, highlights the importance of nurses using the UK Medical Eligibility Criteria (UKMEC)4, created by the FSRH to support clinicians to check eligibility and suitability when delivering contraceptive care.
‘It is so important for new practice nurses coming in, or existing practice nurses who have never dealt with contraception, to treat it like your Bible,’ she tells Nursing in Practice. She stresses how vital it is that all nurses stay ‘up to date’ with the tools available to support patients.
Ms Lewis also emphasises that nurses should be aware of availability issues with contraception. She cites ‘supply problems’ with some oral contraceptives and says practice teams should work collaboratively, with pharmacy colleagues for example, to help ensure access.
She underlines the value of GPNs for contraception support and family planning services. ‘General practice nurses can provide their patients with a plethora of information and safe and effective contraception from both oral and long-acting reversible contraception.
‘Patients can be assessed within familiar surroundings by the practice nurse they are familiar with and trust,’ she concludes.
Helping to debunk myths around contraception
There is an ongoing role for GPNs in dispelling myths around contraception, and those who spoke to Nursing in Practice say they ‘regularly’ hear concerns from patients about the impact on their fertility, as well as worries about the health implications of specific types of contraception.
Women’s health nurse in North Norfolk Donna Loose stresses the importance of ‘breaking that down, giving good education, enabling provision of services and opening up those conversations about how everything works’.
‘Everything for me boils down to education: empowering the person to understand what is going on in their body and what they are taking and what it is doing,’ she says.
Social media influence
Jodie Crossman, a sexual health specialist nurse and co-chair of the STI Foundation, says she is regularly asked ‘if contraception affects long-term fertility, so there must still be a lot of rumours around about this’. And she has seen ‘a lot of discussion on social media’ around wanting to be ‘natural’.
‘I think it’s important to listen to these discussions while at the same time helping patients to avoid pregnancy if they are not planning one,’ she says.
‘Our “natural” evolutionary bodies want us to reproduce, so although it is good to be aware of your own hormones and how these can affect you, it’s also important to protect yourself from STIs and unintended pregnancy.
‘Synthetic hormones can also be very helpful in managing the symptoms of chronic conditions, but it’s important to listen to the individual patients concerns and needs.’
Listening to patients
Nurses must help to debunk myths by ensuring that ‘any advice they give is evidence-based, but also listening and taking seriously people’s concerns’, adds Ms Crossman. ‘If contraception choice is more of a discussion rather than just “take these pills”, people are more likely to find a method they are happy to stick with.’
The GPNs we spoke to suggest the contraceptive pill is still popular among patients, although many also want what they describe as a period – which is a withdrawal bleed from the pill.
Ms Crossman says she has seen ‘a lot of people’ moving to LARC methods such as the implant and the coil, and that this could be in part because of difficulties faced during the pandemic ‘where it was harder to get a repeat prescription of pills’.
But there is also ‘a move away from hormonal methods, or people wanting to use the lowest amount of hormones possible’, she adds. ‘A lot of this is due to negative experiences of contraception, but it may also be the popularity of apps like Natural Cycles and discussion on social media – particularly TikTok – about awareness of your body’s natural cycle.’
References
- FSRH Statement on latest UKHSA and OHID Sexual and Reproductive Health profile statistics, 2023. Link
- NHS Digital. General Practice Workforce, 31 July 2023. Link
- The Health Foundation, 2022. A quarter of GP and general practice nursing posts could be vacant in 10 years. Link
- FSRH. UK Medical eligibility criteria 2016. Amended 2019. Link
