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CCGs must invest in primary care to lower teenage pregnancy rates

GPs and primary care providers can make a huge impact on stats such as rates of teenage pregnancy, argues Dr John Ashcroft, but it will take leadership from clinical commissioners to succeed where PCTs have failed

Health headlines proudly reported recently that the teenage pregnancy rate was at its lowest since 1969. The stats are a cause for celebration, in my view. Teenage pregnancy and early motherhood are often associated with poor educational achievement, poor physical and mental health and poverty. For a young woman to have a baby early in life is widely regarded as being ‘caused by inequalities, and a cause of inequalities’ - a sort of health and social inequalities roundabout.

At the same time the UK has, or recently had, the highest rate of teenage pregnancy in Europe. I say ‘recently had’, because in the last three or four years teenage pregnancy rates have fallen by 20-25% in most areas, with a near 10% reduction in the last year alone.

But the battle over better access to contraceptives has a long history. In 1998 the last Labour government decided to major on reducing inequalities, particularly health and social inequalities. The Social Exclusion Unit was asked by the Prime Minister to study the causes of teenage pregnancy, and in 1999 a report was published that set out a ten-year national strategy. Central to this was the foundation of the Teenage Pregnancy Unit (TPU) - its main target was a 50% reduction in under-18 conception rates by 2010. The emphasis was on improving access by providing contraception via school nurses, emergency contraception from pharmacies and social outreach services. What happened in general practice, and the type of contraception being used, was essentially ignored: the view was that teenagers who fell pregnant didn’t go and see their GP.

How wrong they were. A whole series of papers were produced by a team in Nottingham that showed that 90% of teenagers who had a termination had been seen in their general practice in the year before. Some 70% had seen the GP for contraception, and usually walked out of the door with the oral contraceptive pill (a method known to have a high failure rate, especially in teenage years). Though this research was led by led by Prof Mike Pringle (who has been RCGP president twice) and Dr Dick Churchill (who chaired the RCGP teenage health group) it had no impact on policy.

Initially all looked well, with small reductions to rates in the first few years. But there was always a niggling doubt that the TPU hadn’t actually done anything. There had been a Pill scare in the mid-1990s, and teenage pregnancy rates had gone up afterwards. A similar rise and subsequent fall had happened before when the numbers of teenagers attending family planning clinics had fallen, following confidentiality concerns surrounding the Gillick case.

The TPU didn’t actually start spending money until 2002-3, and from then to 2007 there was no change in teenage pregnancy rates at all. In fact in 2007, the teenage pregnancy rates rose. This finally led to a review of the strategy in 2008. The TPU had failed, not because of the lack of evidence, or leadership from the medical profession, but because of a much more serious problem of attitude towards primary care, and general practice in particular.

In 2008 there was finally a significant change in direction from the DH, a statement on contraception and pregnancy with an emphasis on LARCs. More money - some £25 million - was announced from the comprehensive spending review to ‘improve access to contraception’ and ‘ensure equitable access to LARC methods, training and workforce’. How much of that actually found its way through PCTs into the front line and general practice, is questionable - certainly in my area we didn’t see any of it. There was some TV and magazine advertising to support LARCs use, but it was stopped by the current Government.

Make LARCs a priority

The only thing that seems to have changed, and stayed, is the introduction of LARCs in to QOF. A simple tick-box to say that you have discussed LARCs when prescribing hormonal contraception. Could this really make such a difference? The change in prescribing was large enough to be see within a year. A report from NICE in September 2010 on the uptake of their guidance on LARCs that was published in 2005, noted that ‘there has been a large increase in the prescribing of implants since early 2009’. Just when that tick-box hit our screens and when after 10 years of the teenage pregnancy strategy rates of teenage pregnancy actually appear to have started to fall for real. There could be other reasons, but it fits very well with what we have seen in other countries like the USA, where they have seen falls in teenage pregnancy also associated with better contraceptive use.

This should be a wakeup call for GPs: we make a real difference when advising on contraception. It’s also a wakeup call for politicians and the DH. If they want to deliver real change for the health of the population, particularly women, then they have to listen to clinical leaders and evidence, and engage with general practice.

CCGs have an opportunity to achieve what PCTs where meant to deliver but failed to. PCTs where set up, as their name suggests, to develop primary care. It was the clear vision of John Hutton, the minister who set up PCTs, that developing primary care could help reduce health inequalities. But that didn’t happen. They didn’t develop primary care, and health inequalities actually got worse.

I’m not sure we can publish that - obviously the national figures are out but I don’t have time to get the stats together to stand that statement up. Would it be OK to say instead, PCTs had 10-year targets to deliver 50% reductions in under-18 conception rates from a generous starting point of the 1998 post-Pill scare peak. I’ve yet to hear any champagne corks popping - none of them even came close. When you look at the numbers and the evidence, the opportunity was clearly there: so, CCGs, over to you.

Dr John Ashcroft is a vice-chair of Derbyshire LMC and a GP in Ilkeston.

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