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NHS Borders Enhanced Service Programme for Primary and Community Care

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|Local Enhanced Service for Contraceptive Implants (Nexplanon) 2013/2014 |

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|Background |Contraceptive implants provide excellent contraceptive protection over a long period. Nexplanon (which replaces |

|and aims |Implanon) is the only progesterone-only contraceptive implant currently licensed in the UK. It is inserted |

| |subdermally and is designed to provide long-acting hormonal contraception for 3 years. Its failure rate is |

| |reported as less than 0.1 in 100 women becoming pregnant when using the implant over a 3 year period1. |

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| |All currently available LARC methods are more cost effective than the combined oral contraceptive pill if used |

| |for one year or more, with implants being more cost effective than injectable contraceptives such as Depo |

| |Provera. |

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| |Use of contraceptive implants is increasing in line with national targets and priorities such as the QOF Sexual |

| |Health indicators, which encourage the promotion and use of LARC methods in Primary Care as one of a number of |

| |routes by which a reduction in teenage pregnancy rates is hopefully achievable. |

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| |Implant fitting and removal is not undertaken by all clinical practitioners in general practices. Although |

| |provision of these services in Primary Care can be classed as Minor Surgery procedures, funding for these has |

| |not historically been provided under the Minor Surgery Direct Enhanced Service (DES). This Local Enhanced |

| |Service (LES) therefore has been established to resource practices that offer and provide contraceptive |

| |implants, as part of a range of contraception choices, remunerating those GPs who are fitting and removing |

| |Nexplanon implants in the community.[1] |

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|Timeframe |12 months (from 1st April 2013 - 31st March 2014) |

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|Objectives and desired outcomes |Part 1 – GMP services |

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| |Participating GP practice requirements: |

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| |Accreditation, Clinical Skills and Competencies |

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| |Implant insertion/removal is one of the areas of contraceptive provision associated with relatively high levels |

| |of litigation. The most important factor influencing the incidence of problems relating to insertion and removal|

| |is the competence of the professional inserting the device. High quality patient information and advice also |

| |influences client satisfaction as well as improving continuation rates with LARC methods. Local audit and |

| |published data suggests that fewer than 30% of women should have implants removed at less than one year. |

| |Adequate counseling, in particular with respect to abnormal bleeding patterns, can reduce the number of women |

| |requesting early removal. |

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| |Health professionals who insert (and remove) progestogen-only implants should be appropriately trained, maintain|

| |competence and attend regular updates. Maintaining expertise in fitting and removal can be difficult and |

| |requires commitment from the practitioner. Practitioners should have undertaken appropriate training based on |

| |modern, authoritative medical opinion e.g. the current requirements set down by the Faculty of Sexual and |

| |Reproductive Health Care (FSRH) or the Letter of Competence in Sub dermal Implants (LoC-SDI). Accreditation |

| |involves demonstration of skills required for counselling for implants, knowledge of issues relevant to implant |

| |use, problem management and observation of insertion and removal. In addition, a minimum number of supervised |

| |insertions and removals, as specified by the FSRH should be completed. Evidence of maintaining skills should be |

| |sought by recertifying according to the FSRH guidelines and attending regular updates. Clinicians who have |

| |previously provided services prior to this enhanced service and who satisfy at appraisal and revalidation that |

| |they have such continuing medical experience, training and competence (being considered equivalent to the |

| |requirements set down by the FSRH) as is necessary to enable them to continue to offer this service shall be |

| |deemed professionally qualified to do so. |

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| |For your reference as required, please find below e-mail communications sent from Dr Ailsa Wylie, Clinical Lead |

| |Sexual and Reproductive Healthcare, Borders Sexual Health originally circulated in March 2011 to provide clarity|

| |on the local position regarding the FSRH amnesty for the Diploma, Letters of Competence regarding the fitting of|

| |implants and coils and agreed CPD and activity to maintain skills. |

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| |[pic] [pic] |

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| |Further information around the requirements of those fitting implants can be found at: |

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| |Although GP Minor Surgical procedures have a low incidence of complications, it is important that practices |

| |providing minor surgery continue to operate to the highest possible standards of clinical practice to reduce the|

| |risks of potential procedure-associated infection. |

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| |Record Keeping |

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| |Clinicians carrying out Implant fitting or removal are required to obtain patient consent in line with GMC |

| |guidance and to make appropriate clinical records - either via paper based or electronic clinical systems - |

| |using appropriate read codes (see below). |

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| |Recommended information to be recorded includes: |

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| |Patient name |

| |Relevant Patient Clinical/Reproductive and Sexual History |

| |Counselling process undertaken/patient information given: |

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| |Patients should be given verbal/ written details about the lifespan of the implant, side-effects and |

| |effectiveness in a format appropriate to their needs including the use of translators if required) |

| |See link below to patient information leaflet which may be of use: |

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| |Any contraindications |

| |Injection site and any problems with insertion/removal |

| |Type, batch number and expiry date of implant |

| |Details of any follow-up arrangements or adverse reactions |

| |Name/Designation of person(s) completing the procedure |

| |For removals: time since inserted and reason for removal |

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| |Read Codes |

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| |EMIS read codes which practices may wish to use to aid data recording and searches are as follows: |

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| |Insertion of Nexplanon                EMISNQIN 77 |

| |Removal of Nexplanon                EMISNQRE132 |

| |Replacement of Nexplanon        EMISNQRE 138 |

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| |Practices are required to record data to support contract monitoring. This may be requested as evidence by P&CS |

| |as part of payment verification or contract review. |

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| |Practices should therefore be in a position to report the following data should this be required: |

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| |Have an up to date register of patients who have been fitted with a contraceptive implant by the practice. |

| |Record the number of implants removed by the practice and reasons for removal and duration of implant being in |

| |situ following insertion, if known |

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| |Assessment and Follow-up |

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| |Although routine annual checks are not required (and are not funded under this LES), women experiencing problems|

| |should obviously be seen promptly in general practice. Practices should ensure the timely removal of the implant|

| |where appropriate for any reason including implant-associated problems or at the expiry of device. Alternatives |

| |to removal (such as the addition of the combined oral contraceptive) should always be considered first in women |

| |experiencing irregular bleeding patterns. |

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|Reporting and payments |Practices are required to report how many Nexplanon insertions and removals have been carried out by their |

| |clinicians on a quarterly basis, on the NHS Borders GMS2 Quarterly Enhanced Services Activity Return form, |

| |already in use for other Enhanced Service returns such as Minor Surgical procedures. The return should also |

| |indicate how many implant removals were carried out less than 12 months after the date of insertion. |

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| |Payment per type of service: |

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| |Nexplanon insertion £ 42.62 |

| |Nexplanon removal £ 85.24 |

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| |A current budget of £30,000 per annum has been allocated to this Enhanced Service. This will be reviewed at the |

| |end of the first year once practice activity is better understood. |

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|Acknowledgements |Thanks to NHS Lothian, Derby City and Sheffield whose existing enhanced services have helped inform this LES |

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NHS Borders Enhanced Service Programme for Primary & Community Services

Local Enhanced Service for Contraceptive Implants (Nexplanon) 2013/2014

Please sign and return this completed form only to confirm your participation

Forms should be returned to P&CS by Friday 19th April 2013

Practice Name: ____________________________________

Practice No: ______________________________________________

Signed for and on behalf of the Practice: _____________________________

Please print name and designation: __________________________________

Date: _______________________________________________________________

Notice Period

In the event of a practice being unable to maintain the service for the duration of the contract or wishing to opt out, an appropriate period of notice will be agreed with NHS Borders (normally 3 months).

The payments will be subject to the normal payment verification processes.

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[1] NICE LARC quick reference guide Oct 2005

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